LIBRARY OF CONGRESS. 



Shelf ..Z.4l 



UNITED STATES OF AMERICA. 



f 

V 



OUTLINES 



PATHOLOGY AND TKEATMENT 



OF 



SYPHILIS 



AND ALLIED VENEREAL DISEASES 



BY 



HERMANN VON ZEISSL, M. D. 

LATE PROFESSOR AT THE IMPERIAL-ROYAL UNTVERSITr OF VIENNA 



SECOND EDITION, REVISED 

By MAXIMILIAN VON ZEISSL, M. D. 

PRIYAT-DOCENT FOR DISEASES OF THE SKIN AND SYPHILIS, AT THE IMPERIAL-ROYAL 
UNIVERSITY OF VIENNA 




AUTHORIZED EDITION. TRANSLATED, WITH NOTES, 

By H. RAPHAEL, M. D. 

ATTENDING PHYSICIAN FOR DISEASES OF GENTTO-URINARY ORGANS AND SYPniLIS, 

BELLEVUE HOSPITAL OUT PATIENT DEPARTMENT : MEMBER NEW YORK. 

COUNTY MEDICAL SOCIETY, ETC. 




NEW YORK 
D. APPLETON AND COMPANY 

1886 



\ 



>'\ 



COPYKIGHT, 1886, 

By D. APPLETON AND COMPANY. 



All rights reserved. 



PREFACE TO THE AMERICAN EDITION. 



A treatise on Syphilis by one who has devoted his entire 
life to the study of this disease, and whose experience is the 
result of observation and treatment of upward of thirty thou- 
sand patients in private practice and in the wards of the 
Allgenieine Krankenhaus of Vienna, needs little additional tes- 
timony to attest its value. As a clinical observer of venereal 
diseases, and as a teacher, Professor von Zeissl stood de- 
servedly high in Europe. The concise and graphic descrip- 
tion of the various forms of venereal affections, the accurate 
delineations of the different phenomena of the pathological 
lesions, the terse and detailed account of the symptomatology 
and characteristic manifestations of the various phases pre- 
sented by the different specific diseases, the conscientious 
records of results obtained, bear evidence of the scientific 
thoroughness with which the investigations were pursued, and 
therefore must serve as a valuable guide to those desiring to 
study them. The prominence given to pathology in this work 
indicates the value placed upon it by the author as a means 
to the proper understanding of the diagnosis and treatment of 
the various venereal affections ; and if it can not be said that 
the work contains an abundance of remedies and formulae for 
the treatment of the different phases of the different diseases, 



iv PREFACE TO TEE AMERICAN EDITION. 

neither on the other hand is it overladen with polypharma- 
ceutical combinations. 

The few notes and prescriptions added by the translator 
will not, he hopes, be deemed superfluous. 

H. Eaphael. 

New York, May, 1886. 



PREFACE TO THE SECOND EDITION. 



The first edition of this book was composed for the pur- 
pose of placing in the hands of the student a brief guide to 
aid him in the study of Syphilis. Having been requested by 
my father to revise the second edition, it occurred to me that 
the reader would be pleased with it still more if, by making it 
as brief as possible, it should be as graphic and perfect in 
the description of the morbid picture of venereal diseases as 
possible. I sought to diminish the size of the book by omit- 
ting certain special subjects, giving greater prominence to 
clinical descriptions. Some chapters, which are only theo- 
retically important, or methods of treatment that are only of 
historical interest, have been briefly sketched. The syphilitic 
affections of the skin were taken entirely unaltered from the 
former edition, while the chapters on therapeutics of gonor- 
rhoea, of epididymitis, of strictures, of chancres and syphilis, 
as also the chapter on visceral syphilis and hereditary syphilis, 
have been almost entirely rewritten. Here and there parts of 
the fourth edition of the " Lehrbuch fur Syphilis," issued by 
my father and myself, were used. Professor von Schrotter aud 
Professor Mauthner were so kind as to write the articles on 
syphilitic affections of the larynx, trachea, and eye. I am 
fully aware that the book offers little that is new, but it is not 
intended that it should spread any new doctrines ; it claims 



vi PREFACE TO THE SECOND EDITION. 

only the modest task of presenting a comprehensible picture 
of venereal diseases and their treatment as briefly as possible 
to the practical physician, whom time will not permit to read 
extensive works upon every special branch of our science. 

It only remains for me to express the hope that this book 
will receive the same friendly judgment as the first edition, 
and that I shall succeed in concisely reporting my father's 
ideas, and at least preserve what he created. For the words 
of our great poet find their application in science too : 

" "Was du ererbt von deinen Vatern hast, 
Erwirb es, um es zu besitzen." 

Von Zeissl. 
Vienna, March, I884. 



CONTENTS. 



PAGE 

Introduction 1 

The Venereal Contagions 3 

SECTION I. 

GONORRHOEA (TRIPPER) VENEREAL CATARRH. 

Site of Gonorrhoeal Affection and Mechanism of Gonorrheal Infection . .17 

Factors that usually favor Gonorrhoeal Infection 18 

Gonorrhoea of the Male Urethra 19 

Pathological Alterations in the Male Urethral Canal produced by the Gonor- 
rhoeal Disease 25 

Morbid Phenomena which occur as Co-effects and Sequela? of Urethral Gon- 
orrhoea in Men 29 

Prognosis of Gonorrhoea in the Male 30 

Prophylaxis against Gonorrhoea, and Treatment of Acute and Chronic Gonor- 
rhoea in Men 31 

The Indirect or Internal Treatment of Gonorrhoea of the Male Urethra . . 42 
Catarrh of the Glans Penis and Prepuce, Balanitis, Balano-Blenorrhcea, Bala- 

nopyorrhoea, Balanopostheitis 46 

Phimosis and Paraphimosis 47 

Differential Diagnosis and Treatment of Catarrh of the Glans Penis and of the 

Resulting Inflammatory Phimosis and Paraphimosis . . . .48 
Affections of the Lymphatic Vessels and Glands in consequence of Gon- 
orrhoea . . . .51 

Inflammation of the Vasa Deferentia and the Epididymis . . . .52 
Treatment of Inflammation of the Spermatic Cord and Epididymis . . .56 

Chrome Hydrocele. Hernia Aquosa 58 

Inflammation of Cowper's Glands 60 

Morbid Alterations that are produced in the Prostate by Gonorrhoea of the 

Urethra 61 

Inflammation of the Seminal Vesicles in consequence of Urethral Gonor- 
rhoea 66 

Functional Disease of the Seminal Vesicle and of the Testicle. — Spermatorrhoea, 
Seminal Emissions, Pollutio Diurna 67 



viii CONTENTS. 

PAGE 

Diseases of the Bladder caused by Urethral Gonorrhoea . . . .69 
Diseases of the Kidney that are produced by Urethral Gonorrhoea . . 74 
Gonorrhoea of the Female 78 

1. Gonorrhoea of the Yulva. . . ■ . . . . . .78 

2. Gonorrhoea of the Vagina 80 

3. Complications of Vulvo-vaginal Gonorrhoea 83 

(a) Diseases of the Glands of Bartolini and their Ducts . . .83 
(6) Inflammation and Abscess of the Lymphatic Vessels in the Labia 
Majora and Minora, and of the Lymphatic Glands of the In- 
guinal Folds 85 

4. Urethral Gonorrhoea in the Female 88 

Gonorrhoea of the Rectum 89 

Gonorrhoea of the Mouth and Nasal Cavities 90 

Gonorrhoea of the Eye (Ophthalmia Gonorrhoica Blenorrhoica) . . .90 

Treatment of Gonorrhoeal Ophthalmia 92 

The Effects or Sequelae of Gonorrhoea in general and of Urethral Gonorrhoea 

in particular 93 

Gonorrhoeal Rheumatism 94 

Condylomata ; Vegetations ; Spitze or Moist Warts 97 

Stricture of Urethra 101 

SECTION II. 

SOFT CHANCRE OR CHANCROID. 

Action of Chancrous Virus and Development of the Soft Chancre . . .109 

Pathology of the Soft Chancre 110 

Course, Duration, and Cicatrization of the Soft Chancre .... 112 

Varieties of Soft Chancre 113 

Site of the Soft Chancre 115 

Differential Diagnosis of the Soft Chancre . . . . . . .118 

Prognosis and Treatment of the Soft Chancre 121 

Prophylactic Treatment 122 

Abortive Treatment ..... . . . . . 122 

Curative or Methodical Treatment 123 

Diseases of the Lymphatic Vessels and Glands (Lymphangioitis and Adenitis) 

in consequence of Soft Chancres 128 

Buboes originating as a Result of Soft Chancres 132 

Site, Shape, and Size of Chancroid Buboes 135 

Differential Diagnosis and Prognosis of Buboes 137 

Treatment of Diseases of Lymphatic Vessels produced by Chancroids . .139 

The Treatment of Open Buboes . 141 

Fistulae in consequence of Suppurating Buboes . 142 

SECTION III. 

SYPHILIS. 

General Conception 145 

Nature and Vehicle of the Syphilitic Virus 145 



CONTENTS. ix 

PAGE 

The Transmissibility of Syphilis, or the Various Ways in which Syphilitic In- 
fection may take place 146 

Transmission of Syphilis by Vaccination. — The Relation of Vaccine Lymph 

to Syphilitic Virus 147 

Transmissibility of Syphilis to Warm-blooded Animals .... 149 

First Manifestation of the Action of the Syphilitic Virus .... 149 

Anatomy of the Syphilitic Initial Sclerosis 151 

Site and Form of the Huntcrian Induration 153 

Combined Effects of the Syphilitic Virus and of the Chancroid Virus . .155 

Inoculability of the Sclerotic Ulcer 156 

Significance, Duration, Course, and Differential Diagnosis of the Syphilitic 

Initial Sclerosis [Hard Chancre] 156 

Unicity of the Syphilitic Infection 158 

Affections of the Lymphatic System occasioned by Beginning Syphilis . .159 
Induration and Hypertrophy of the Peripheral Lymphatic Vessels in con- 
sequence of Syphilitic Infection . 165 

The Syphilitic Diathesis 166 

Pathological Alteration of the Blood of Syphilitic Persons . . . .167 

Eruptive Fever of Syphilis 168 

Time of Eruption of General Syphilis 169 

Localization of the Syphilitic Foci 169 

The Cachexia produced by Syphilis 170 

Combination of Syphilis 170 

Succession and Phases of Syphilitic Affections 171 

Development, Course, and Duration of Constitutional Syphilis . . .172 

Mortality of Constitutional Syphilis 172 

Development of Lymphatic Glandular Swellings originating in the Course of 

Syphilis (Multiple Adenitis) 174 

Morbid Lesions of the Skin caused by Syphilis (Syphilitic Diseases of the 

Skin— Syphilides) 175 

Definition and Classification of Syphilitic Skin-Diseases . . . .180 

1. The Erythema Syphilide, Erythema Syphiliticum Maculosum et Papu- 

latum, Roseola Syphilitica, Syphilitic Spots 180 

2. Papular Syphilides 186 

(a) Lenticular, Papular Syphilide 188 

(b) Small Papular Syphilide (Syphilis Papulosa Miliaris) . .189 

(c) The Papular Syphilide, or Squamous Syphilide of the Palms of the 

Bands and Soles of the Feet (Psoriasis Palmaris et Plantaris), 
and Syphilitic Diffused Affection of the Epidermal Strata of 
the Hands and Feet (Syphilis Cornea) 192 

(d) The Humid or Moist Papules, or Flat Condylomata ; Papules 
Humides ; Pustula Fcetida Ani ; Pustules, Plates, etc., of Va- 
rious Authors . . . 196 

3. Pustular Syphilide 201 

(a) The Acne-like Syphilide 202 

(b) Varicella-like Syphilide, or Varicella Syphilitica . . . 204 

(c) Impetigo Syphilitica . 206 



x CONTENTS. 

PAGE 

(d) Ecthyma Syphiliticum ... ... . 209 

(e) Rupia Syphilitica 211 

4. Nodular Syphilide of the Skin ; Tubera Syphilitica ; Tubercula Syphi- 
litica ; Syphilitic Nodes of the Cutis and of the Subcutaneous Cellu- 
lar Tissue (Gummata) ; Syphiloma, according to Wagner . . .213 

The So-called Pigment Syphilis 222 

Syphilitic Affections of the Hair 222 

Syphilitic Disease of the Nails 223 

Syphilitic Affections of the Mucous Membrane 226 

(1) Syphilitic Erythema of the Mucous Membrane ; Syphilitic Catarrhal 

Inflammation ; Erythema Syphiliticum Membranse Mucosae . . 226 

(2) Syphilitic Papules on the Mucous Membrane 22*7 

(3) The Syphilitic Node or Gumma of the Mucous Membrane . . 231 

Syphilis of the Mouth and Fauces 233 

Syphilitic Disease of the Tongue 238 

Syphilitic Disease of the (Esophagus . . 244 

Syphilitic Disease of the Stomach and Intestines 245 

Syphilitic Affections of the Liver 247 

Syphilitic Affection of the Spleen 250 

Syphilitic Affection of the -Pancreas and of the Salivary Glands . . .250 

Syphilitic Affections of the Larynx and Trachea 251 

Syphilitic Acute and Chronic Catarrh 252 

" Papules 253 

" Infiltrations, Gummata 254 

" Ulcers 256 

" Perichondritis . . 261 

" Cicatrices 261 

" New Growths 263 

Syphilitic Affections of the Bronchi and Lungs 263 

Syphilitic Affection of the Kidney, Suprarenal Capsule, and Bladder . .265 
Syphilitic Affections of the Testicle and Spermatic Cord . . . . 265 
Syphilitic Affections of the Ovaries, Fallopian Tubes, and Uterus . . .270 
Syphilitic Affections of the Mucous Membrane of the Genital Organs of Both 

Sexes . . . ... 271 

Syphilitic Affections of the Corpora Cavernosa Penis 272 

Syphilitic Affections of the Breasts . . 273 

Syphilis of the Heart and Blood-Yessels 273 

Affections of the Brain, Spinal Cord, and Peripheral Nerves, as a Result of 

Syphilis 274 

Syphilitic Affections of the Nose 280 

Syphilitic Affections of the Auditory Passages . . . . . 284 

Syphilitic Affections of the Eye 285 

Iritis Syphilitica 285 

Affections of the Ciliary Body, the Choroid, and Yitreous Humor . . 290 

Inflammation of the Retina and Optic Nerve 292 

Affections of the Cornea, Conjunctiva, and of the Eyelids . . . 293 
Affections of the Orbits, Lachrymal Sac, and of the Muscles . . . 294 



CONTENTS. xi 

PAGE 

Syphilitic Affection of the Bones and their Envelopes 295 

Syphilitic Inflammation of the Periosteum ; Periostitis Syphilitica . .297 

Ostitis Syphilitica 300 

Cicatrization of Syphilitic Ulcers of the Bones 302 

Site and Effects of Periostitis and Ostitis 303 

Differential Diagnosis of Affections of the Bones produced by Syphilis . . 304 

Syphilitic Affections of the Joints 305 

Syphilitic Affections of the Cartilages 307 

Syphilitic Affections of the Muscles, Tendons, and Sheaths of Ten- 
dons 303 

Syphilitic Affection of the Bursa? 310 

Endemic Syphilis ; Leproid or Syphiloid Disease 311 

Malignant or Galloping Syphilis 312 

Hereditary Syphilis 315 

Manifestations of Congenital Syphilis 319 

Macular Syphilide in the Infant ; Erythema Maculo-papulatum Syphiliticum 

Neonatorum 320 

Papular Syphilide in the Infant 321 

Pustular, Gumroous, and Hemorrhagic Syphilide in the Infant . . . 322 

Syphilitic Affections of the Mucous Membrane in the Infant . . . . 325 

Syphilitic Affections of the Bones and their Envelopes 326 

Affections of the Eye in consequence of Hereditary Syphilis . . . 328 
Morbid Alterations of the Internal Organs resulting from Hereditary 

Syphilis 329 

Diagnosis and Prognosis of Congenital Syphilis 333 

Syphilis Hereditaria Tarda . . . 334 

Treatment of Syphilis 334 

Prophylaxis of Syphilis 337 

Treatment of the Initial Lesions of Syphilis ; the Hunterian Indurated Chan- 
cre ; the Indolent, Multiple, and Strumous Buboes .... 340 

Treatment of Secondary Phenomena of Syphilis 342 

(A.) Expectant Method 342 

Therapeutical Application of Iodine and Iodine-Salts against Syphilis . . 345 

(B.) Medical Treatment 345 

The Treatment of Syphilis by Vegetable Remedies ..... 350 

Therapeutic Use of Mercury 352 

Mercurial Preparations which are best adapted to be introduced into the Blood 

through the Digestive Organs 353 

External Application of Mercury and its Preparations 358 

(a) Mercurial Inunction Treatment 358 

(6) Hypodermic Mercurial Treatment of Syphilis 371 

(c) Treatment of Syphilis by Mercurial Fumigations .... 374 

(d) Treatment of Syphilis with Baths containing Mercury . . . 375 

(e) Treatment of Syphilis by the Application of Mercurial Suppositories 

to the Mucous Membrane of the Rectum 376 

Pathogenetic Effects which Mercury and its Preparations may produce during 

Treatment ... 376 



xii CONTENTS. 



Effects of Cold- Water Treatment, Sea-Baths, and Sulphur Thermal Baths on 

Syphilis and on Hydrargyrosis 380 

Syphilophobia and Mercuriophobia on Hypochondria Mercurialis . . ,381 

Syphilization 382 

Treatment of some of the Local Syphilitic Affections 383 

The Nursing of the Syphilitic Child and the Treatment of Congenital 

Syphilis 388 



INTEODTJCTIOK 

Infectious discliarges from the genital organs of both sexes, 
and ulcerations on those parts, must have been known in olden 
times, even in the remotest antiquity. There is an allusion to 
an " unclean seminal discharge " in the third book of Moses 
(Leviticus, chap, xv), and the sanitary regulations prescribed by 
Moses himself indicate conclusively the actual infectious na- 
ture of such seminal discharges. It is likewise seen, from the 
writings of the old Greek and Roman physicians, that they 
treated ulcers of the genital organs which were caused by con- 
tagion. 

At the end of the fifteenth century many persons were at- 
tacked, as in an epidemic, with morbid phenomena, especially 
diseases of the skin, whose origin the physicians' of those times 
regarded as being due partially to telluric and partially to astral 
causes. These affections were supposed to originate in a gen- 
eral deterioration of the cardinal secretions of the body and 
the liver as being the fountain of the disease. JSTot until it 
became apparent that these diseases prevailed among the troops 
of Charles YIII, which occupied Naples in 1495, and occurred 
especially among those women with whom they had sexual in- 
tercourse, did many physicians become convincd that the dis- 
eases in question originated by transportation from one person 
to another — this transportation or infection occurring espe- 
cially during sexual congress, and starting with an affection 
of the genital organs. These circumstances led Fernelius 
and Bethencourt to call this disease venereal, or the veneria, 
and also "lues venerea." For the same reason it was also 
called mentulagra (from mentula, penis), when it attacked 
men, and pudendagra when it attacked women. At the time 
when it prevailed as a pest it received various names, based 
1 



2 PATHOLOGY AND TREATMENT OF SYPHILIS. 

mainly upon geographical grounds. The French called it " mal 
de Naples " and " la grosse verole " ; the Spaniards, " las bu- 
bas" (pocks). The Germans and Italians called it "mal de 
France " ; the Poles, the " Dutch disease " ; the Dutch and 
English, the "Spanish"; the Orientals, the "French"; the 
Portuguese, the " Castilian " ; the Persians, the " Turkish " ; 
and the Chinese, the "disease of Kanton" (Kouang tong 
Tschouang). But all these designations were supplanted by 
the name of syphilis, which has been universally adopted. 
This term was first applied to the disease by Hieronymus Fra- 
castorius, deriving it from a shepherd by the name of " Syphi- 
lus," whom he apostrophizes in an ode, as the first to suffer 
from -this disease because he had offended the gods. Others 
derive the name syphilis from the Greek word cncfrXos, broken ; 
others, again, from the words en;? and <j>i\ia. 

The infectious discharges from the genital organs are called 
in males, "gonorrhoea" — fluxus sive profluvium seminis, from 
r) yovrj, semen, and pelv, to flow ; in females, " fluor " ; in Ger- 
man, " Tripper." The terms blennorrhosa and blennorrhagia 
mucifluxus, from to fiXevvos, or rj fiXevvoa, mucus, and pelv, or 
prjyvovcu, were first used by Swediaur. 

We are indebted for the designation of the word " chancre," 
as applied to a sore on the genital organs originating from sex- 
ual intercourse, to the French, who substituted the word chan- 
cre for cancer, which Celsus had selected to designate this dis- 
ease. With the word cancer Celsus wished to describe the 
spreading, corroding, malignant character of the ulcer. The 
physicians of the thirteenth and fourteenth centuries selected 
the words "caries," "caroli," or "taroli pudendum," to des- 
ignate such malignant contagious ulcers. 



THE VENEKEAL CONTAGIONS. 

Fernelius was one of the first to properly comprehend the 
connection between diseases of the genital parts and syphilis. 
He suggested the hypothesis of the existence of an animal poi- 
son which he called the venereal poison. This virus, Fernelius 
believed, developed not only in the purulent secretion of cer- 
tain ulcers of the skin and mucous membrane that originate 
during sexual intercourse, but also in the muco-purulent dis- 
charge of the inflamed or catarrhal affected mucous membrane 
of both sexes. From these two affections of the genital or- 
gans, Fernelius contended that the venereal virus passes into 
the secretions of the body and then attacks sometimes one or- 
gan and then again another. He was therefore of the opinion 
that syphilis, until then such a mysterious disease, resulted 
from well-known affections of the mucous membranes and of 
the skin covering the sexual organs, which we to-day desig- 
nate as chancre and gonorrhoea (clap). 

The opinion that gonorrhoea and chancre were the com- 
mencement of syphilis prevailed till the second half of the 
eighteenth century. In the year 1767 Balfour, an English 
surgeon, positively asserted that gonorrhoea and syphilis were 
essentially distinct diseases. Balfour's assertions, however, 
were stoutly opposed by John Hunter, who, in 1767, first 
instituted comparisons between the two diseases by perform- 
ing inoculations with the secretions of venereal catarrhal af- 
fections of the mucous membranes and of venereal ulcers of 
the skin. Hunter inoculated the penis and prepuce (whose is 
not stated) with pus which he derived from the urethra of a 
patient presumably affected with gonorrhoea. As ulcers de- 
veloped from these inoculations, upon which induration of the 
lymphatic glands of the right groin soon supervened, and a 
few months later ulcers of the tonsils and a roseola eruption 



4: PATHOLOGY AND TREATMENT OF SYPHILIS. 

became superadded, which symptoms of constitutional syphilis 
were promptly cured by mercury, Hunter deemed the identity 
of gonorrhoea and chancre as complete, and consequently also 
of the contagion of gonorrhoea and syphilis as conclusive. The 
difference in the form of the manifestations of this contagion 
he believed to be due only to the differences in the anatomical 
structures upon which the lesion was produced. Upon the 
secreting mucous membrane the poison in question produces a 
catarrhal, upon the general cutaneous covering an ulcerative, 
process. 

The first one to oppose Hunter in this matter was Ben- 
jamin Bell, of Edinburgh. He adduced the following facts : 
Two young persons scarified the skin of their glans penis and 
prepuce with a lancet, and allowed bits of charpie dipped in 
gonorrhoeal matter to remain in contact with the scarifications 
for forty-eight hours. In one of the young men a balano-blen- 
norrhcea ensued ; in the other, some of the dripping pus gained 
an entrance into the urethra, in consequence of which a catar- 
rhal disease developed in two days in this canal. On the other 
hand, one of the experimenters, by carrying the pus of a 
venereal ulcer of the skin of the genital organs upon a probe 
several millimetres deep into the urethral canal produced a 
painful ulcer at tins place, which was followed by a suppurat- 
ing bubo. Notwithstanding this and many other similar ex- 
periments, the virus of gonorrhoeal with chancre contagion was 
supposed to be identical till the thirtieth year of the present 
century, when Ricord first took sides in the matter. By the 
aid of Recamier's vaginal speculum, which was used very 
little by his predecessors and contemporaries, Ricord disproved 
Hunter's views, by the fact that venereal ulcers may exist 
upon the mucous membrane of the vagina and of the neck of 
the uterus, and consequently the vaginal discharge may be 
tainted with that of the chancre. From 1831 to 1837 he per- 
formed 667 more inoculations with gonorrhoeal matter, and 
from none of these did any chancre-ulcers result. Finally, 
Ricord proved that not infrequently the matter that exudes 
from the urethra is due to a chancre-ulcer situated in that 
canal, which upon inoculation produces a pustule from which 
a chancre will develop. 



THE VENEREAL CONTAGIONS. 5 

With these and other experimental researches all apparent 
contradictions were explained, and the independence of the 
gonorrheal contagium was incontestably proved in every way, 
both as regards its indirect as well as its direct effect. 

With the progress of science and more carefully observed 
clinical facts it soon became manifest that not all chancres 
were followed by syphilitic lesions. Hunter, who, although he 
looked upon gonorrhoea and ulcers on the genitals arising 
from sexual contact as the effects of one and the same poison, 
nevertheless maintained that not all the ulcers on the genital 
organs are of syphilitic nature. He only designated such ulcers 
on the genital organs chancre that were followed by syphilis. 
According to Hunter, the chancre was distinguished from all 
other sores on the sexual organs by a dense, hard, sclerotic base 
and by elevated indurated borders (Hunterian induration). 
All otherwise constituted non-indurated ulcers on the genitals 
were, in his opinion, not chancres ; they were simple, ordinary, 
non-infectious ulcers or secondary syphilitic sores. These sec- 
ondary syphilitic sores were said to be distinguished from the 
primary sores by the fact that they were not callous, did not 
spread rapidly, produced no adenitis, were not auto-inoculable, 
and healed rapidly. At first, Ricord made no distinction be- 
tween the indurated and non -indurated ulcers, calling them 
both ulcerating chancres, and deeming both to be the effects of 
one and the same virus. He called the virus " chancre-poison 
or primary syphilitic poison," which in some cases — not, how- 
ever, in all — is followed by syphilis, and which, according to 
the grade and phase of development, he embraced in the 
category of secondary and tertiary affections. Gradually, 
however, he approached the position held by Hunter, in so far 
as to admit that only that chancre which was situated upon 
a hard base, or left behind it a hard cicatrix, was capable of 
producing general syphilis, and such chancres he therefore 
called " infecting chancres." The induration thus established 
was looked upon as a criterion of commencing blood-poison- 
ing. The reason why induration resulted in one case and not 
in another, he maintained, was not due to the difference in the 
character of the virus, but partly to its more or less weakened 
power to infect (virulescence) and partly to the difference of 



6 PATHOLOGY AFD TREATMENT OF SYPHILIS. 

tissue upon which it was implanted. He regarded the Hunte- 
rian or the infecting chancre merely as a variety of chancre-in- 
fection, and which is additionally distinguished from the other 
varieties by the fact that it occurs but once upon one and the 
same individual during his whole life. Finally, Ricord, like 
Hunter, held that the primary sore was the sole fountain of 
syphilis and denied the ability of secondary manifestations to 
transmit the disease from one person to another. 

This theory of Ricord, which has been called the unity or 
identity theory, was soon shaken by experience, which con- 
flicted with it. It was repeatedly observed that a person had 
simultaneously a soft and an indurated chancre near each other, 
that many persons had multiple contagious soft chancres, with- 
out being affected subsequently by syphilis, while in another 
person a single hard ulcer was followed by constitutional mani- 
festations. Lastly, numerous confrontations of infected and 
infecting patients showed that the indurated ulcer was always 
produced by similar or secondary syphilitic ulcers of the per- 
son infecting, while a soft chancre, attended only by local 
symptoms, propagated through contact only a local sore which 
was soft in character. All these circumstances led one of 
Ricord's scholars, Leon Bassereau, in 1852, to establish the 
proposition that the soft chancre was not a source of syphilis. 
In conjunction with Clerc, another pupil of Ricord, he pro- 
pounded a new theory, namely, the duality theory, by which 
he maintained the existence of two essentially different chancre- 
poisons — the soft and the indurated — both of which are in- 
debted to two totally different contagions for their origin. 
The soft-chancre sore, he maintained, was always a local disease, 
and was only capable of acting perniciously upon the general 
system by causing suppuration in the adjacent lymphatic 
glands. But the hard chancre always led to blood-poisoning 
and constitutional symptoms. Though, to be sure, it likewise 
causes swelling of the adjacent lymphatic glands, they never 
or very seldom pass on to suppuration, and the pus they con- 
tain can not by propagation produce a chancre. This new 
theory of Bassereau and Clerc was soon adopted by Ricord and 
Fournier, and formulated in the law that each variety of chan- 
cre was only capable of propagating its own kind. 



THE VENEREAL CONTAGIONS. 7 

The soft chancre or chancroid may be produced by inocu- 
lation upon sound as well as upon syphilitically diseased tis- 
sues ; the hard chancre can only be reproduced by inoculation 
upon healthy tissues, and never upon any that is already syphi- 
litic. 

Clerc, it is true, succeeded, by inoculations with matter from 
a hard chancre, in producing ulcers, which he designated by 
the name of " chancroide," and which he believed to be of a 
similar nature as the soft chancre. He therefore maintained 
that the soft chancre was a bastard product produced by in- 
oculating a syphilitic person with an infecting chancre, which, 
if it were once developed, was capable of propagating itself 
in an endless series, without ever assuming the primitive char- 
acter of an infecting chancre. 

In Ricord's " Lecons sur le chancre " cases were, however, 
reported which were supposed to prove that Clerc's chancroids 
were capable of reproducing the infecting chancre and the in- 
fecting chancre a soft chancre, even upon an individual who is 
not syphilitic. In order to save the dualism theory that was 
now apparently tottering, Rollet, of Lyons, suggested the hy- 
pothesis that both poisons can be transmitted simultaneously, 
and the result of this transmission is a " mixed " chancre (chan- 
cre mulet), whose auto-inoculation upon the same or upon a 
syphilitic person would produce positive results. "While the 
French physicians continued to entangle themselves by one- 
sided views of the forms of the sores in a labyrinth of contra- 
dictions and names, other investigators deeming the contagions 
that formed the basis of the ulcers to be of prime importance, 
and supported by experiments as well as by exact clinical ob- 
servations, were soon able to throw new light upon the action 
of the soft chancre and of syphilis. The results of the re- 
searches instituted by Wallace, Waller, Heinecker, Lindemann, 
Daniellsen, Yon Barensprung, Hubbener, Lindwurm, Hebra 
and Kosner, Pelizzari, H. Zeissl, and many others, together 
with our own clinical experience, enable us to lay down the 
following principles : 

1. The poisons of the soft chancre and of syphilis are totally 
different from each other. They have only in common the 
external quality that both of them are most frequently con- 



8 PATHOLOGY AND TREATMENT OF SYPHILIS. 

tracted during sexual congress ; hence soft chancres, like pri- 
mary syphilitic lesions, are more often found upon the genital 
organs of both sexes. 

2. The pus and tissue detritus, disorganized by the chancre- 
infection, are the vehicles by which the poison of the chancre 
is conveyed. The virus of syphilis is united especially with 
the disorganized detritus of the syphilitic inflammatory prod- 
uct, and also with the blood, and probably with the semen of 
syphilitic persons. The experimental inoculations performed 
with the blood of syphilitic patients produced positive results 
in some though not in all cases. Why all syphilitic parents 
do not beget syphilitic children is still unexplained. 

3. Pus from an abscess or the contents of a non-syphilitic 
eruption on a syphilitic person, when transmitted to a healthy 
individual, have not hitherto, in our experiments, produced 
syphilis. 

4. The poison of a soft chancre reproduces itself, if trans- 
mitted upon a syphilitic person, in the same manner as in a 
healthy one. The discharges from a soft chancre situated upon 
a syphilitic individual will always produce a soft chancre only. 

5. If the secretions of a suppurating specific primary lesion 
are inoculated upon its possessor or upon another syphilitic per- 
son, there results upon some of the luetic (syphilitic) patients 
so inoculated an ulcer ; but this ulcer need not necessarily be a 
primary specific ulcer, because a person who is already luetic 
can not while he is still syphilitic again acquire syphilis. We 
maintain the correctness of the proposition that a primary 
syphilitic lesion, as such, can not be reproduced upon its pos- 
sessor. 

6. The minimum quantity of blood-particles which is apt 
to be present in a chancre of a syphilitic person is not capable 
of producing syphilis. But if syphilitic inflammatory prod- 
ucts, such as papules or nodules, are made to undergo suppura- 
tion and disorganization by implanting upon them chancroid 
virus, a pustule may be produced, and if this detritus be then 
inoculated upon a non-syphilitic person, an initial syphilitic pri- 
mary sclerosis or hard chancre will develop. 

7. Little as the purulent sputum of a syphilitic person when 
transmitted to a healthy person can produce in the latter syphi- 



THE VENEREAL CONTAGIONS. 9 

lis, so little will the pus of an abscess or the contents of a non- 
specific eruption from a syphilitic patient produce syphilis upon 
a healthy individual. Only the pus or the structural debris of 
the products especially belonging to syphilis is capable under 
favorable circumstances of producing syphilis. The supposi- 
tion of the existence of a mixed chancre, in the sense advo- 
cated by the Lyons school, we have discarded long ago. To 
be sure, we have to admit that the secretion of a soft chancre, 
if implanted upon a syphilitic eruption, will exercise its de- 
structive action in the same way as upon perfectly healthy tis- 
sues; but if the disorganization of the syphilitic eruption 
through the chancrous virus has once been established, the re- 
sulting ulcer will then have nothing in common with the soft 
chancre. Now, if the pus of an inflammatory syphilitic prod- 
uct — for instance, a syphilitic papule brought to the stage of 
suppuration by irritating it with the secretion of a soft chan- 
cre — is implanted upon a healthy person, syphilis will be pro- 
duced ; while the same soft chancre if inoculated upon a syphi- 
litic individual at any place that is unaffected by syphilitic 
inflammatory product will occasion a soft chancre only ; and 
this, again, if inoculated upon a healthy person, will give rise 
to a soft chancre only, and produce no syphilis. 

8. The syphilitic primary effect or lesion may appear in 
three forms : First, as a superficial erosion or deep ulcer with 
hard borders and hard base ; second, as a hard nodule or ker- 
nel, which in the progress of the disease breaks down ; and, 
third, as a hard nodule, that from its origin to its complete 
resolution shows not the least trace of breaking down. The 
syphilitic primary lesion is the first manifestation of general, 
constitutional syphilis. 

9. The most important data of the syphilitic primary lesion 
are the peculiar cartilaginous hardness, whether the syphilitic 
chancre appears as a simple nodule or as a hard ulcer; next, 
the indolent swelling of the lymphatic glands that accompanies 
it and the scanty suppuration. 

10. If a syphilitic person is inoculated with ordinary pus 
or any other irritating fluid, upon an incision made with a clean 
vaccinating-lancet, there will sometimes result, in consequence 
of this irritation, a syphilitic ulcer. 



10 PATHOLOGY AND TREATMENT OF SYPHILIS. 

11. There is no chancrous syphilis, no primary and no sec- 
ondary syphilis. It is only proper to speak of chancre-syphi- 
lis when it is desired to indicate that the chancroid poison was 
mixed with syphilitic poison. The Hunterian induration may 
indeed be looked upon as the first manifestation of syphilis 
that is about to develop, but is by no means to be regarded as 
a primary evil whose virus in the course of absorption will 
become converted into the so-called secondary syphilitic virus. 

To the principles enunciated under § 5 we must add a few 
words and also refer the reader to the chapter on the " Inoc- 
ulability of the Indurated Ulcer," which will be found fur- 
ther on. 

It is an irrefutable fact that it is possible, by inoculating a 
luetic individual with syphilitic pus and syphilitic ulcer-detri- 
tus, to produce pustules and ulcers. Now, the question arises, 
What is the nature of those ulcers, which Clerc, for the sake of 
brevity, styled " chancroides," and what happens if a healthy 
person is inoculated with one of them? Before we answer 
these questions, we have to premise a few remarks. It has 
been ascertained, through experiments made by many physi- 
cians, that even the pus from ordinary skin-disease — for in- 
stance, a pimple of the face — may in some cases be used for 
repeated auto-inoculation on healthy persons. In this way the 
principle of the greater vulnerability of the skin of a syphi- 
litic person was partially refuted, and we must restrict our- 
selves to the statement that we can obtain positive results in 
some cases by inoculating healthy persons with any kind of 
pus, but that such inoculations take effect more readily in 
syphilitic persons. It is, therefore, easy to comprehend why 
we can so often produce ulcers by inoculating syphilitic per- 
sons with the pus of a syphilitic eruption. The question next 
arises, What happens when we inoculate a healthy person with 
matter taken from such a " chancroid " ? The result may be 
of three kinds : First, the inoculation may not take ; or, second, 
an ulcer ensues which remains localized ; or, third, a syphilitic 
primary lesion develops, followed by consecutive general syphi- 
lis. Why an inoculation fails we are unable to explain. The 
second and third conditions we consider as explicable in this 
wise : The syphilitic contagium is not chemically soluble, and 



THE VENEREAL CONTAGIONS. \\ 

is not uniformly distributed in the blood. Now, if we bear in 
mind Chauveau's experiments with vaccine lymph, we can as- 
sume the following facts : That in vaccinating we only trans- 
mit lymph and such particles of matter which accidentally con- 
tain no syphilitic virus. In this case, if the vaccination takes, 
we will only produce a simple local ulcer, which does not bear 
the characters of a syphilitic primary lesion. But if we trans- 
mit pus and such particles as do contain syphilitic virus, we 
will, in the third case, produce a syphilitic primary lesion that 
will be followed by general, constitutional syphilis. The vac- 
cinated sore that remains localized may be compared to the in- 
oculated ulcers, which may be produced on luetic and healthy 
persons with ordinary pus, and which may be reproduced by 
repeated inoculations. But if it is intended to regard these 
inoculated ulcers as soft chancres, then every inoculated ulcer 
produced with any kind of matter would have to be considered 
as soft chancres — a statement which we are not yet inclined to 
make. 

From what has here been said, it is evident that we must 
adhere to the duality doctrine of Yon Barensprung and H. 
Zeissl, and consequently assume the existence of three venereal 
poisons, namely, the contagium of gonorrhoea, of the (soft) 
chancre, and of syphilis. We will first discuss the morbid pro- 
cesses of gonorrhoea, then the soft chancre, and lastly syphilis. 



SECTION I. 

GONORRHOEA (TRIPPER), VENEREAL CATARRH. 

The morbid process known as gonorrhoea is a catarrh of 
the urethral mucous membrane. With the word catarrh, how- 
ever, only one symptom — namely, the hypersecretory activity 
of the affected mucous membrane is brought into prominence. 
Every hypersecretion presupposes the presence of a hypere- 
mia. This hypersemia, in the vast majority of cases of gonor- 
rhoea, is very active, because, as a rule, it is the immediate con- 
sequence of a pathological irritation. However, mucous mem- 
branes in general, and the mucous membrane of the male 
urethra in particular, are exceedingly sensitive to morbid irri- 
tation. But, as is known, there are also stasis-catarrhs in which 
the hypersemia is passive in character, and consequently comes 
on very gradually. The immediate effect of hypersemia is a 
serous transudation into the mucosa and the submucous mem- 
brane (oedema of the mucosa), and an increased activity of the 
secretory powers of the mucous follicles, which produce a clear 
serous fluid (serous catarrh). Still another effect of the hy- 
persemia is an increased formation of epithelial cells and the 
production of mucus (epithelial and mucous catarrh). When 
the irritation of the tissues is very slight an increased forma- 
tion of epithelial cells only will ensue ; when it is somewhat 
severer but still moderate, the production of mucus becomes 
notably increased. But the increased flow of mucus does not 
only emanate from the open, patulous acinous glands, but also 
from the epithelial cells of the mucous membrane, whose 
protoplasm becomes transformed into mucous substance (mu- 
cous metamorphosis) — a procedure that has its analogy in the 
corneous transformation of epidermis-cells. If a still more 



GONORRHCEA, VENEREAL CATARRH. 13 

intense irritation takes place, the epithelial cells will form pus- 
cells either through endogenous cell-formation or nuclear fis- 
sion, and the cavities of the follicles are filled up with a fluid 
containing pus-cells (inflammatory and purulent catarrh). As 
a result of the continued suppuration, many of the affected fol- 
licles are liable to undergo ulceration, which may involve the 
submucous tissue, and result in limited defects of the mucous 
and submucous tissues (catarrhal ulceration). 

Now, just as we may speak of a serous, epithelial or mu- 
cous, and purulent catarrh, so is it possible to differentiate be- 
tween a serous, epithelial or mucous, and purulent gonorrhoea. 
The distinction, however, between these forms can not be 
strictly maintained. In all forms of catarrhs, just the same as 
in gonorrhoea, more or less epithelial cells, mucous and pus 
corpuscles may occur together ; one or the other of these three 
elements may, however, preponderate in a given case, and thus 
establish the character of the secretion. 

The serous, epithelial, and mucous catarrhs, as regards gon- 
orrhoea, are the forerunning stages of the purulent catarrh of 
gonorrhoea. The disease may be arrested at any one of these 
stages by any inhibiting influence ; or, on the other hand, the 
inflammatory and purulent catarrh of gonorrhoea in its retro- 
grade development may undergo resolution from stage to stage 
to the mucous, epithelial, and serous form. 

If the pressure of the blood in the capillaries of the catar- 
rhally affected mucous membrane becomes so great that they 
rupture, capillary haemorrhage will ensue. The escaped blood- 
corpuscles cause the purulent discharge to become brown or 
black in color, and the bleeding mucous membrane to assume 
an inky appearance (the black or Russian gonorrhoea). 

All the phenomena described above which go to make up 
the anatomical symptom complex of a catarrh in general, and 
hence, also, of the venereal kind, undergo in the latter espe- 
cially a rapid transformation, so that the whole morbid process 
runs its course in a few weeks and the mucous membrane may 
again be restored to a perfectly normal condition (acute gonor- 
rhoea). Before, however, the mucous membrane again becomes 
perfectly normal, it remains sensitive for a long time and the 
least cause may reproduce the catarrh. These relapses may 



14 PATHOLOGY AND TREATMENT OF SYPHILIS. 

recur very often, and their frequent repetition tend to render 
greater the disposition to contract new catarrhal attacks ; these 
relapses always last longer too. Through the recurrence of 
frequent relapses the morbid condition is apt to become per- 
manent (chronic gonorrhoea). 

The views now prevailing concerning the genetic factors 
of gonorrhoea are not very clear. At any rate, it is an undeni- 
able fact that the disease may be transmitted from one person 
to another. The question, therefore, arises whether the trans- 
mission can be explained by the fact that the morbific action 
of the secretion of gonorrhoea develops its irritating properties 
in the usual manner in the second individual, or whether the 
gonorrhoeal secretion possesses a peculiar specific power by 
virtue of which it infects. 

While some investigators look upon the morbid process of 
gonorrhoea as a result of ordinary irritation of the mucous 
membrane, others claim that it is produced entirely by a con- 
tagion, which is reputed to possess such intense power that it 
can act not only by indirect contact but also at a distance (aura 
gonorrhoea). 

In regard to the hypothesis, that any irritation of the mu- 
cous membrane, be it mechanical or chemical, is capable of 
producing a muco-purulent secretion, it is a fact that has been 
a matter of daily observation for a long time. Through sim- 
ple friction of the vulvar mucous membrane (manustupration), 
the frequent introduction of instruments (bougies or catheters) 
into the male urethra, the impaction of calculi debris in the 
latter canal, the wearing of pessaries in the vagina for a length 
of time, catarrh of the mucous membrane of these organs has 
frequently been produced. Swediaur engendered an obstinate 
discharge from his urethra by injecting it with ammonia. 
Osmic acid, when placed upon a mucous membrane, will pro- 
duce catarrh upon it ; even the vapor of the acid is capable, 
as is well known, of causing serious catarrhal irritation of the 
conjunctiva palpebrarum et bulbi and of the mucous mem- 
brane of the larynx and trachea. The decomposing secretion 
of the glans penis, containing as it does ammonia, may occa- 
sion blennorrhoea of the glans penis. The decomposing men- 
strual blood, the lochia, discharge from a cancer, a chancre in 



GONORRHCEA, VENEREAL CATARRH. 15 

the urethra, all may induce a hypersecretion of the urethral 
follicles. The catarrhal hyaline secretion of the uterus, un- 
der certain conditions, will give rise in some men to a muco- 
purulent discharge from the mucous membrane of the 
urethra. 

As every catarrhal secretion may become aggravated into 
an inflammation attended by suppuration, it was supposed that 
the growth of the infecting power of the secretion kept pace 
with the growth of the catarrhal process till it became aggra- 
vated into a purulent condition. Some authors, therefore, 
maintain that the gonorrhceal discharge only becomes infectious 
when it has become purulent ; that the serous secretion during 
the prodromal stage and the mucous secretion during the stage 
of resolution, if they contain no pus-cells, possess no infectious 
properties. In our practice, however, we have seen numerous 
instances where men troubled only with the prodromal phe- 
nomena of gonorrhoea, i. e., a prickling sensation at the 
meatus urinarius, where not a trace of pus could be found 
in the urethral discharge, infected their wives and mistresses. 
We have likewise had the experience that the slight mucous 
secretion of gleet is capable of communicating a gonorrhceal 
disease. 

The facts here produced compel us to assume that the mor- 
bific potency of a gonorrhceal infection is not to be found in 
the pus-cells, but in a specific catalytic power of the secretion 
— i. e., in a contagion which adheres to the epithelial as well as 
the pus cells, and which we are not able to isolate any more 
than other kinds of contagium. The hypothesis that an ani- 
mal or vegetable parasite (Neisser's gonococcus) forms the 
basis of a gonorrhceal contagium has not yet been satisfactorily 
demonstrated. 

[This gonococcus, which Neisser discovered in 1879, he 
claims occurs so constantly in the pus of gonorrhoea, that he 
and other investigators were led to consider the virulency of 
the disease as being due to this micro-organism. This proposi- 
tion was subsequently confirmed by the successful inoculation 
of a pure culture of gonococcus. The gonococci are distin- 
guished by their relative size, and also by usually occurring in 
groups of two, four, and more couples, whose origin may be 



16 PATHOLOGY AND TREATMENT OF SYPHILIS. 

recognized by the division of the primitive coccus. These 
cocci are flat on the surfaces, facing each other like "split 
peas," and the groups formed of two or more couples are like 
German rolls facing one another. This marked tendency to 
form groups that consist of numerous pairs of single cocci, 
distinguishes this from other kind of cocci, which may happen 
to be in the urine and discharges from the sexual organs, and 
which likewise occur in the form of diplococcus, but never 
constitute such large groups. 

The gonococci are found in the pus, some of them free 
and others upon and probably also in the epithelial and pus 
cells, but not in the granules. By examining a prepared sec- 
tion of the conjunctiva of an infant afflicted with blennorrhcea 
neonatorum, Bumm proved that the gonococci are only capable 
of penetrating cylindrical and not flat epithelial cells, that they 
penetrate down between epithelial cells, but reach only the 
topmost layer of the submucosa, sometimes arranged as if they 
followed the capillaries of the lymphatic vessels.] 

True, it is now generally admitted that there must be a 
gonorrhoeal contagion, because daily experience has shown that 
a minimum quantity of gonorrhoeal discharge is sufficient to 
morbidly affect a normal mucous membrane, as is often the 
case in the production of gonorrhoeal conjunctivitis. Accord- 
ing to the views of most experienced physicians, catarrhal se- 
cretions of other mucous membranes are also more or less con- 
tagious. We are, therefore, of the opinion that there are irri- 
tative catarrhs — i. e., catarrhs that may be produced by various 
irritants, chemical agents, and disorganized physiological and 
pathological secretions, and such catarrhs as are produced by a 
specific contagious matter, and which should be designated as 
purulent or virulent gonorrhoea. Although the irritative ca- 
tarrh is pre-eminently attended by a muco-epithelial secretion, 
still one is not justified, from this property of the secretion, in 
saying that its genesis is not virulent, because a mucous catarrh 
may be the beginning and end of one that is virulent. In 
regard to the prognosis, however, we can say that the mucous 
catarrh, as a rule, is irritative, and its cure much easier to 
effect than the other forms. 



GONORRHCEA, VENEREAL CATARRH. 17 

Site of the Gonorrheal Affection and Mechanism of the Gonor- 
rheal Infection. 

Venereal catarrh mostly affects the mucous membrane of 
the genital organs of both sexes ; bnt it may also be conveyed 
by contiguity to the mucous membrane of the rectum and 
uterus, and by transportation of the secretion to remote mu- 
cous membranes — for instance, the conjunctiva. Yenereal ca- 
tarrh most frequently occurs upon the mucous membrane of 
the male urethra, and the vagina and vulva in the female ; less 
frequently the cervical canal of the uterus, and rarer still the 
female urethra, are involved. We have never had an oppor- 
tunity of seeing gonorrhoea of the nose and mouth. 

It is easy to conceive why the female vagina and vulva and 
the glans penis should by contagion become catarrhally affected. 
The morbific matter readily comes in contact with the genital 
parts during coitus. Less easy to comprehend, however, is it 
how the morbific agent can, during copulation, exercise its in- 
fluence upon the mucous membrane of the male urethra, the 
meatus being but a narrow slit, whose lips well-nigh close the 
opening of the urethra hermetically. We opine the modus 
operandi to be as follows : The external orifice of the male 
urethra during the act of coition, by the forcible intrusion of 
the membrum virile (erect penis) into the vagina, is mechani- 
cally slightly opened. By the separation of the lips a vacuum 
occurs, and by the laws governing such physical conditions a 
portion of the contagious and irritative fluid that happens to 
be in the vagina is sucked into the urethra and effectively re- 
tained there, because during the retraction of the organ that 
follows the lips of the meatus are closed again. That this ex- 
planation is correct is proved by the following facts : Of sev- 
eral men who successively copulate with the same woman, 
those will not become diseased who on account of their intense 
excitability ejaculate their semen when their membrum virile 
has barely been introduced within the vulva. Men who break 
off the act of coition before ejaculating the semen become 
affected sooner than those who complete it naturally yet 
quickly. Men who micturate immediately after copulating are 
less often affected than those who do not take that precaution. 
2 



18 PATHOLOGY AND TREATMENT OF SYPHILIS. 

The spermatic fluid during ejaculation, and the urine during 
micturition, seem to wash out the urethra from behind forward 
in a similar manner. 

Factors that usually favor Gonorrheal Infection. 

Short acts of coition frequently repeated, and abruptly 
broken off, favor gonorrheal infection, because, as the orgasms 
become longer, the female genitals become more irritated and 
incited to discharges. Hence it happens that copulation re- 
peated at frequent intervals with a woman suffering from ute- 
rine catarrh, or one who is menstruating often, produces serous, 
epithelial, or mucous gonorrhoea in the male. If the catar- 
rhal uterine secretion and the menstrual blood, per se, were 
capable of acting as irritants, the number of urethral catarrhs 
would be far greater. Even healthy, loving couples very often 
show, after a night of immoderate indulgence in sexual inter- 
course, the symptoms of commencing urethral and vaginal ca- 
tarrh. 

The relative size of the genital organs is also a factor that 
should be taken into consideration here. The greater the fric- 
tion which the vagina must suffer from a large membrum vi- 
rile, the more profuse and thicker will the catarrhal secretion 
be. A short, erect penis will scarcely ever be affected by a 
uterine secretion. 

Men with large meatuses become diseased more easily and 
quickly than those who have a very narrow orifice. A urethra 
terminating in a hypospadic meatus is oftener and more eas- 
ily infected than a normal one, because the gonorrhoeal secre- 
tion of the vagina, in accordance with the laws of gravitation, 
accumulates mostly upon the posterior wall of the vagina, and 
consequently the contact of the urethral orifice of the hypo- 
spadiac with the infecting and irritating matter occurs more 
readily. 

Another factor that favors gonorrhoeal infection is drunk- 
enness, because the act of copulation when attempted by a 
person in an intoxicated condition will take a longer time be- 
fore terminating in ejaculation, and the membrum virile is 
consequently retained longer in the vagina. 

A man who has but recently recovered from an attack of 



GONORRECEA, VENEREAL CATARRE. 19 

gonorrhoea is much more readily infected than one who was 
not affected with the disease. 

There is no peculiar condition of the blood that will render 
a person especially prone to be affected with the gonorrhoeal 
contagium. 

Gonorrhoea of the Male Urethra. 

We make a distinction between serous, mucous, or epi- 
thelial and purulent catarrh of the male urethra. The cause, 
or circumstance, which in a given case produces a serous or 
mucous catarrh only, and stamps it with that character, con- 
sists mainly in the property which the morbific matter exer- 
cises upon the urethra. Upon that also depends the rapid 
or tardy development of the catarrh. The richer the mor- 
bific matter is in pus the quicker will the disease ensue, 
and the more intense will it be. Mucous secretion, for in- 
stance, catarrhal uterine discharge, or fluids entirely free from 
pus, like menstrual blood, or mechanical irritation of the ure- 
thra, as a rule give rise to serous, epithelial, or, at the most, 
mucous catarrh, while the purulent discharges of inflammatory 
catarrh of the urethra and vagina generally cause an inflamma- 
tory or purulent catarrh. 

The serous and mucous catarrh of the male urethra is either 
initial or terminal. The initial catarrh soon subsides under 
an appropriate treatment ; under unfavorable circumstances, 
however, it will merge into an inflammatory or purulent catarrh. 
The terminal catarrh, as a rule, assumes a protracted course, 
and is exceedingly obstinate. The initial serous and mucous 
catarrh has its site in the fossa navicularis of the urethra, the 
terminal catarrh in the pars membranacea and prostatica. The 
secretion of the terminal serous and mucous catarrh is frequent- 
ly more opaque and glutinous than that of the initial catarrh, 
because, owing to its site in the pars prostatica, the tubuli pros- 
tatici are also involved. The secretion of the prostate gland 
produced in consequence of unnatural and prolonged sexual 
irritation, and which finds its way into the urethra, is not to 
be mistaken for the mucous discharge of the initial serous and 
mucous catarrh. 

The inflammatory catarrh of the male urethra (urethritis 
purulenta, acute inflammatory gonorrhoea) runs its course in 



20 PATHOLOGY AND TREATMENT OF SYPHILIS. 

the following manner : Twenty-four or forty-eight hours, sel- 
dom later, after an act of intercourse, the person feels a slight, 
unpleasant prickling sensation at the meatus which leads him 
to micturate frequently. Gradually, however, the mucous 
membrane of the meatus becomes swollen and a slight but 
clear translucent and tenacious secretion makes its appearance, 
which, under the microscope, shows mucous corpuscles and a 
few epithelial cells. If the patient is made to pass his urine 
into a glass vessel, the discharge will be seen to contain numer- 
ous flocculent and thread-like structures that swim about in 
the urine, which is otherwise clear. The discharge being slight, 
it therefore becomes inspissated in the meatus, sealing it up, 
thus preventing the patient from micturating easily. It gen- 
erally requires a few moments before the thickened discharge 
is washed away by the stream of urine. These symptoms are 
met with alike in both the serous and mucous gonorrhoea. 
In purulent gonorrhoea, however, the scene is soon changed. 
The tickling is transformed into a burning, painful sensa- 
tion. The mucous membrane of the meatus swells up so that 
it bulges outwardly and the orifice looks like the mouth of a 
fish. The secretion becomes more profuse, thicker, and ac- 
quires a greenish or yellowish-green, color. If at this stage of 
the disease a small quantity of the urine is collected in a glass 
vessel, it will appear opaque on account of the purulent secre- 
tion that is mixed with it. The pus-corpuscles swim about 
like particles of dust or minute animalcules in the urine, and 
then gradually sink to the bottom of the vessel because their 
specific gravity is heavier than that of the mucous flakes and 
epithelial cells of the mucous catarrh and the urine itself. The 
discharge slightly colors blue litmus-paper red, and under the 
microscope shows predominantly pus-corpuscles along with 
mucous and epithelial cells, sometimes also a few blood-cor- 
puscles* Yirchow has called attention to the fact that gonor- 
rhoea! pus-corpuscles are larger than those of ordinary pus. The 
purulent discharge appears by the fourth or fifth day, rarely 
not until the twelfth or fourteenth. As the discharge from 
the anterior part of the urethra gradually increases, the difficul- 
ties of urination also increase. The patient micturates either 
with a good, deal of pain, the urine coming away only in drops. 



GONORRHOEA, VENEREAL CATARRH. 21 

or in a thin, weak, and interrupted stream, because the urethra, 
owing to inflammatory swelling of the mucous membrane, is 
temporarily narrowed, and the smooth, striated, muscular fibers 
of the urethra that propel the stream of urine are partially par- 
alyzed. Occasionally Wilson's muscle, the sphincter vesicae, 
contracts spasmodically, causing intense strangury. The spon- 
gy portion of the penis, like the mucous membrane, is en- 
gorged ; hence the organ is constantly in a semi-erect condition, 
and thus helps to render the urethra still narrower. 

In cases of intense inflammatory gonorrhoea of the male 
urethra, gastric disturbances and febrile movement not infre- 
quently become superadded. The former healthful appear- 
ance of the patient disappears as if by a blow, and he becomes 
pale and sickly-looking. This marked depressed condition of 
the general system is not, however, due to the effect of the 
gonorrhoeal contagion upon the blood, but is the result of the 
constant pain and disturbed sleep. The warmth of the bed 
causes frequent erections, and the swelled mucous membrane 
not being sufficiently distensible is dragged upon by the erec- 
tions of the corpora cavernosa, producing intense pains and 
disturbance of sleep at night. When the patient, despite the 
pain and utter exhaustion, finally falls asleep, he is not infre- 
quently awakened by a painful emission. 

The morbid phenomena here delineated persist for a longer 
or shorter period according to the dietary measures and regi- 
men the patient keeps. Under appropriate measures the swell- 
ing of the urethral canal subsides by the eighth day, and the 
dysuria markedly diminishes. At the beginning or end of the 
third week the purulent discharge decreases and becomes 
poorer in pus-corpuscles, while the mucous and epithelial cells 
begin to predominate. Gradually the mucous discharge also 
changes, so that only a few drops of mucus or muco-purulent 
discharge escapes from his urethra if he has not micturated for 
several hours. If the urine that is passed at this time is col- 
lected in a glass vessel, whitish shreddy structures (gonorrhoeal 
shreds), varying in length, are seen floating in it. If the 
shreds are taken from the urine they will contract into small 
gelatinous lumps, and microscopically are seen to be fatty 
degenerated epithelial cells and pus-corpuscles. These elon- 



22 PATHOLOGY AND TREATMENT OF SYPHILIS. 

gated epithelial shreds may, it is true, originate in the ducts of 
Cowper's or Mery's gland ; still they are not to be considered 
as such in all cases, since they may form at any point of the 
urethral canal. After a while, the quantity of these shreds 
diminishes, and for some time, whenever the patient urinates, 
there may be but one such shred in the urine. Finally, this 
one too disappears, and in the course of six weeks' time a gon- 
orrheal process may be said to have reached its end. So long 
as any of these gonorrheal shreds is noticeable in the urine, 
the least cause may again start up the morbid process that is 
so near expiring. The oftener these relapses occur the more 
difficult is it to cure completely a urethral gonorrhoea. In 
some parts of the mucous membrane of the urethra permanent 
sensitive spots remain, attended by persistent though slight 
muco-purulent discharge. This condition is called gleet (after- 
clap) or chronic torpid gonorrhoea. 

Chronic urethral gonorrhoea may best be described as a 
persistent mucous stage in the retrograde development of the 
disease. Here the discharge containing mucous and epithelial 
cells is very slight, and is only seen at times, especially in the 
morning, at the meatus of the urethra, or, by squeezing the 
parts, a drop of matter is expressed. If the lips of the meatus 
are not agglutinated, micturition is easy, and no general and 
often no local disturbances of sensation are present. In some 
cases, however, the patients complain of occasional prickling sen- 
sations in the region of the fossa navicularis or at some point 
of the perineal part of the urethra, or, again, of some transient 
stitches that extend from the' latter spot to the anal opening. 
These sensations seem to be due to deep pathological altera- 
tions, which, however, vary so much that we are not justified 
in describing them under the common name of " chronic gon- 
orrhoea" — still less so, as a more correct diagnosis would essen- 
tially alter the prognosis and treatment of the disease. 

In acute gonorrhoea of the urethra the dysuria may, owing 
to the intense swelling of the urethral mucous membrane, be- 
come intensified into a condition of actual strangury. The 
turgescence of the capillaries of the mucous membrane may 
attain such a degree that they rupture at various points, some- 
times resulting in severe haemorrhage. The blood that is 



GONORRHCEA, VENEREAL CATARRH. 23 

poured out into the urethra and coagulates there colors the 
purulent discharge reddish-brown or even blackish, and for 
this reason it is also called hcemorrhagic, Mack, and Russian 
gonorrhoea, because it is said to have been of uncommonly fre- 
quent occurrence among the Russian troops engaged in the 
wars at the beginning of the present century, owing to indis- 
cretion in the diet and hygienic regimen. 

Another uncommon feature of the inflammatory urethral 
gonorrhoea in the male is that the inflammation of the epithe- 
lial layer penetrates through the mucous membrane and the 
submucous tissue and involves the spongy portion of the ure- 
thra, in the meshes of which, especially in those of the corpus 
cavern osum urethrse, one or more painful swellings, varying 
in size from a pea to that of a lentil, form. If these peri-ure- 
thral inflammatory foci form in persons who are afflicted with 
frequent erections that last some time, the erections already so 
painful become still more intense, because the spongy portion 
in which the infiltration has taken place not only can not keep 
pace in the erections with the other portions of the erectile 
spongy body, but actually hinder it from becoming erect, and 
cause it to curve like the bow of a violin. This kind of erec- 
tions has been designated chorda venerea (chordee), because 
the patients claim that they have the sensation as if the penis 
is prevented from becoming erect by a tense cord drawn 
through the urethra. Now, in its erections the penis will be 
bent either downward or to one side, according as the corpus 
cavernosum or urethra is affected. Under judicious treatment 
the pains during erections cease in the third week, and the 
peri-urethral inflammatory nodes undergo absorption. If the 
absorption is incomplete, the inflammatory exudative hyper- 
trophies will remain, causing the affected spot of the spongy 
body to become obliterated, and during erections the member 
will curve toward the swelled spot, rendering it difficult of 
introduction into the vagina during intercourse. In some 
cases abscesses form in these peri-urethral infiltrations, which 
subsequently perforate the urethra and give rise to fine fistu- 
lous tracts. These abscesses most frequently break into the 
fossa navicularis in consequence of the inflammatory exuda- 
tion occurring in the sulcus coronarius near the frsenum. 



24 PATHOLOGY AND TREATMENT OF SYPHILIS. 

In chronic gonorrhoea the catarrhal process may likewise, 
through indiscretion in diet or other injurious measures, be- 
come aggravated. The mucous catarrh becomes intensified 
into a purulent one, or even attains to a condition of croupous 
inflammation. This manifests itself in the following manner : 
The patient whose urethra is apparently almost well suddenly 
begins to feel intense itching in the perineal region, and this 
sensation is supplanted in a few hours by violent pains. The 
mucous discharge subsides almost entirely, but there is greater 
difficulty in making water, and the stream of urine becomes 
thinner. If a bougie is introduced, and after its removal a 
syringe full of water is injected, the returning fluid will bring 
away white membranous masses from two to three centimetres 
in length, consisting of a dense band-like or cylindrical fibrinous 
substance which has originated by fibrinous exudation upon 
the epithelial layer of the mucous membrane. These bands 
will break abruptly on being forcibly stretched. On the addi- 
tion of acetic acid they swell up and become clear like fi brine, 
whereas mucus becomes opaque and coagulates into shreds on 
the addition of an acid. According to our experience, this mor- 
bid condition seems mostly to be produced in the membranous 
part of the urethra in consequence of severe irritation by strong 
injections, especially solutions of bichloride of mercury. 

Urethral gonorrhoea has its starting-point in the fossa na- 
vicularis. This is evident from the fact that at the beginning 
of the disease patients complain of an itching sensation, and 
later of pain in this region. But the physician should not 
hastily assume that the gonorrhoea! process tarries in the fossa 
navicularis as long as the patient experiences tickling or pain 
in this locality. In this part of the urethra the sensorium 
commune of the entire territory of the genital organs seems 
to center, for here the patient feels all the morbid sensa- 
tions, in whatever manner or part of the urinary organs they 
may have been produced. Thus, calculi in the bladder, affec- 
tions of the prostate, and many other irritations, produced in 
the deeper parts of the urethra, are felt in the region of the 
fossa navicularis. At the beginning, during the initial serous 
or mucous stage, the congestion is certainly limited to the 
anterior part of the urethral canal ; but after a few days, espe- 



25 

cially in purulent catarrh, the congestion gradually extends 
backward, so that by the eighth or teuth day the entire mucous 
membrane of the pars pendula, and by the beginning of the 
third week that of the pars membranacea, is affected. The 
junction of the pars bulbosa to the pars membranacea of the 
penis, where likewise a navicular fossa forms, and where a num- 
ber of aggregated follicles exist, is the most difficult spot to cure 
— the follicular inflammation forming the greatest obstacle 
in curing a gonorrhoea radically. An inflammatory urethral 
gonorrhoea may be arrested at any point in its progress, from 
the fossa navicularis to the membranous portion, but at this 
point the disease is not only likely to become markedly aggra- 
vated because the existing follicles, that have been alluded to, 
become inflamed and undergo suppuration (gonorrhceal ab- 
scesses), but swelling and thickening of the tissues take place 
here preferably, which, if produced by stasis-catarrhs, will, ac- 
cording to the intensity, duration, and course, seriously affect 
the gonorrhoeal process. But, from experience, we are justified 
in saying that certain constitutional conditions, such as scrofula, 
tuberculosis, anaemia, gout, rheumatism, haemorrhoids, and all 
those irritations which, emanating from the rectum (intestinal 
worms) or bladder (calculi, etc.), are likely to affect the poste- 
rior part of the urethra, also contribute materially toward pro- 
longing a chronic catarrh of the urethra, and make it exceed- 
ingly difficult to cure. 

Pathological Alterations in the Male Urethral Canal produced 
by the Gonorrhceal Disease. 

During the life of the patient it is not possible to see 
throughout the whole extent of the urethra, with the unaided 
eye, the morbid alterations of the mucous membrane of the 
urethra. Examinations on the cadaver seldom offer an op- 
portunity of studying the morbid alterations of the urethral 
mucous membrane ; and the views of most reliable investiga- 
tors, based upon post-mortem research, refer more to such 
morbid lesions which have originated in consequence of a 
protracted chronic gonorrhoea than to alterations resulting 
from the acute form of the disease. The few cases of gonor- 
rhoea! disease which we had an opportunity of investigating 



26 PATHOLOGY AND TREATMENT OF SYPHILIS. 

post-mortem, before the affection of the urethra had entirely 
disappeared, taught us that it only occasions such morbid 
changes as we are accustomed to find in catarrhs of other mu- 
cous membranes. The pathological alterations of gonorrhoea 
of the vaginal mucous membrane in the acute stage, or blen- 
norrhagic affection of the conjunctiva palpebrarum et bulbi, 
will form the truest representation of the lesions resulting from 
the disease under consideration. We find there redness and 
swelling of the mucous membrane, sometimes granulations, 
and not infrequently erosions, which bleed easily. In re- 
gard to the gonorrhceal discharge, in the acute stage of the 
disease, proliferation of the epithelial cells and transformation 
of the epithelium-cells into pus-corpuscles take place, while in 
the torpid stage epithelial cells undergo fatty degeneration 
and hyaline cells abound. Rokitansky expresses himself thus : 
" The catarrhal inflammation of the urethral mucous mem- 
brane has a tendency to run a chronic course. It is either 
uniformly distributed over the entire urethra, or sometimes 
from the beginning, at other times later in its course, is limited 
to one or more spots. These inflamed spots are found at any 
part as far as the prostatic portion, but most frequently at the 
fossa navicularis, and near the bulbous portion of the ure- 
thra. They are recognized by their dark-red color and the 
swelling of the mucous membrane ; sometimes, especially in the 
fossa navicularis, remarkable enlargement of the mucous glands 
and purulent collections are observed. At the same time the 
corpus spongiosum urethrse, at the places mentioned, in its 
innermost layer — at times, indeed, throughout its entire length 
— is swelled, and its meshes diminished in size, and conse- 
quently contains less blood. At these places an unyielding 
swelling, produced in the manner described, is readily per- 
ceived along the urethral canal. The longer the inflammation 
lasts, especially when its intensity is frequently aggravated, 
the less likely is it to get well entirely ; it is more apt to ter- 
minate in thickening of the mucous membrane, or strictures." 
Engel is unable to say a great deal positively regarding the 
diseases of the urethral mucous membrane, because in most 
cases it is impossible to distinguish an acute inflammation 
of the urethra from the chronic variety. Neither produces 



GONORRH(EA, VENEREAL CATARRH. 27 

morbid lesions that are readily perceived or belong to them 
specially, and which are not likely to be met with in a condition 
of apparent health. And the discharge which in inflammation 
of other parts affords definite proof, is generally only limited 
in amount in urethritis — often, indeed, it is greatly diluted, 
changed, or washed away by the current of the urine, and in 
rare instances only is there any thick, purulent secretion. 

The urethral mucous membrane generally becomes thick- 
ened, rough, and dry in chronic gonorrhoea. Occasionally there 
have been found in the region of the bulb, less frequently in the 
navicular fossa, spreading ulcers, one centimetre long, with 
flat, projecting shreddy edges and uneven bases surrounding 
the entire circumference of the urethra, studded with condylo- 
ma-like excrescences (carunculse) and bridles of mucous mem- 
brane (Engel). They originate from the ulceration of the 
follicles found at those points, and in healing form white 
yielding or non-yielding cicatrices, according to the depth to 
which the ulcers have penetrated. In the fossa navicularis 
this ulcerative process may perforate the urethra, and a fistula 
may result, through which urine escapes during the act of 
micturition. To be able to diagnosticate a gonorrheal ulcer in 
the living subject, pure water should be injected several times 
in succession into the urethra. If pus, mucus, blood-corpus- 
cles, and especially structural detritus, come away after each in- 
jection, it is certain that an ulcer is present. Sometimes a 
bougie introduced into the urethra causes intense pain in pass- 
ing over the ulcerated spot. In some cases we found the ducts 
of Cowper's glands dilated to such a degree that they allowed 
the passage of fine probes. 

In the last decade the morbid lesions of the urethra, result- 
ing from various diseases, have been studied by direct ocular 
inspection. 

Desormeaux, as far back as 1853, used a complicated in- 
strument for that purpose, which, has since been considerably 
improved by several surgeons. The simplest apparatus was 
invented by Griinfeld. His instrument consists of an endo- 
scopic tube and a concave mirror ordinarily used in laryngo- 
scopy examinations. Gas, petroleum, or sunlight may be 
made available for illumination. 



28 PATHOLOGY AND TREATMENT OF SYPHILIS. 

The " endoscope," so warmly recommended and employed 
by Griinfeld, is simply an endoscopic tube. It consists of a 
cylindrical metallic or bard-rubber tube, whose ocular end is 
dilated like a funnel, its inner surface blackened, and its 
visceral end open and polished smoothly. This tube is in- 
troduced by the aid of a conductor, and it not only serves the 
purpose of enabling the physician to obtain a view of the ure- 
thra, but also of applying remedies to it. 

Great tact and practical skill in the use of sounds and 
catheters will help one to employ the endoscope successfully. 
The instrument is introduced armed with the conductor, pushed 
into the deepest part of the urethra, when the conductor may 
be withdrawn ; the urethral surfaces may then be cleansed of 
mucus, discharges, etc., either by a plug of cotton- wool upon a 
wire, or by a stream of water from a long-nozzled syringe. 

Three things are to be noted, according to Griinfeld, in 
making examinations by the aid of the urethroscope : 1. The 
funnel, i. e., the shape under which the urethral mucous mem- 
brane presents itself, wherein the larger end of the funnel lies 
contiguous to the internal border of the tube, and the narrow 
end is directed toward the smaller lumen of the urethra ; 2. 
The central figure, i. e., the apex of the funnel corresponding 
to the point in the center of the field of vision, which is occa- 
sioned by the urethral walls meeting at a point ; and, 3. The 
urethral walls, the color and thickness of the mucous mem- 
brane, the condition of its vascular arrangement, its reflex 
sensibility, etc. 

Griinfeld distinguishes the following forms of acute gonor- 
rhoea : 1. Urethritis blennorrhoica ; 2. Urethritis membranacea ; 
3. Urethritis simplex ; 4. Urethritis granulosa ; 5. Urethritis 
trachomatosa ; and, 6. Urethritis phlyctsenulosa or herpetica. 
In tirethritis blennorrhoica the field of vision is profusely cov- 
ered with pus. The funnel form is absent, the central figure 
is irregularly indented, or a single spot is seen from which 
two or three indentations radiate. The swollen mucous mem- 
brane that bulges up into the lumen of the tube is uniformly 
livid in color, and presents defects of reflection corresponding 
to the punctated losses of substance. The edge of the tube pro- 
duces in the thickened mucous membrane a temporary grooved 



GONORRHCEA, VENEREAL CATARRH. 29 

impression, and the mucous membrane bleeds on the slightest 
pressure. In urethritis membranacea, Griinfeld found the 
morbid process limited to a certain part, to which the pus 
firmly adhered, the removal of which caused bleeding. Paral- 
lel with the axis of the urethra several gray or grayish- white 
strips of exudation were found firmly adhering upon the mu- 
cous membrane. In urethritis simplex there is often present 
only a hyper semic condition. Where the mucous membrane 
is somewhat more swollen, it will be found more reddened, 
and several bleeding points will also be detected. In urethritis 
granulosa a small quantity of muco-pus is found in the middle 
of the field of vision, resembling the point of the central fig- 
ure, the funnel is short, the center figure oval and slightly 
shorter, the reflex irregularly triangular, the mucous mem- 
brane of a uniform velvety redness, with a few solitary punc- 
tate elevations. The mucous membrane, in the majority of 
cases, acquires a certain degree of rigidity, as may be per- 
ceived from the gaping of the walls at the central figure. In 
some cases Griinfeld observed a purely granular trachomatous 
swelling. In the forms of urethritis attended by ulcerations, 
urethritis phlyctamulosa or herpetica, Griinfeld found a few 
small circular ulcers which attracted attention by their color 
and sharply defined edges.* 

Morbid Phenomena which occur as Co-effects and Sequelse of 
Urethral Gonorrhoea in Men. 

In gonorrheal disease of the male urethra, certain morbid 
alterations often coexist which have their site beyond the ter- 
ritory of the urethra and its adjacent parts, and which may 
be regarded as the co-effects of the urethral disease, while 
the propagation of the disease may give rise to certain mor- 
bid lesions in contiguous or adjacent organs or parts of or- 
gans. Among the co-effects we may mention balanitis, affec- 
tions of the lymphatic vessels of the penis, inflammation of 



* If the student desires further information upon this subject, he is referred 
to the work of Griinfeld, " The Endoscope in Diseases of the Bladder and Urethra," 
published in the " Deutsche Chirurgie," and to Griinfeld's treatise, " The Endo- 
scopic Examination of the Urethra," in our work on. " Syphilis," fourth edition. 



30 PATHOLOGY AND TREATMENT OF SYPHILIS. 

the inguinal lymphatic glands, condylomata (warts'), and cer- 
tain rheumatoid affections of the joints, sheaths of muscles, 
and bursse. 

Of the diseases which extend by contiguity from the 
urethra to adjacent organs, we may mention affections of 
Cowper's gland, of the epididymis, prostate, bladder, ure- 
ters, and kidneys. Moreover, the morbid lesions produced by 
urethral gonorrhoea, when they supervene upon a severe form 
of the disease, are generally considered as accompanying 
phenomena of the disease; while those lesions produced by 
gonorrhoea of the male urethra and coming on sometime after 
the urethritis was apparently cured (strictures of the urethra, 
prostatic and vesical diseases), are described as sequelae. 

Prognosis of Gonorrhoea in the Male. 

Gonorrhoea of the male urethra affords a less favorable 
prognosis than gonorrhoea of the female urethra and vagina — a 
fact that might be inferred, even after leaving out of consid- 
eration certain co-effects which naturally can not occur at all in 
the female, but which in addition seem to be due to a higher 
function of the epithelial cells of the male urethral tract that 
has not yet been fathomed. To foretell the duration and 
course of a male urethral gonorrhoea is a difficult problem. 
Experience has only taught us so far that, when a mucous 
gonorrhoea has retained this character for several days after 
exposure to infection, it will under an appropriate treatment 
disappear sooner than a purulent gonorrhoea. This presump- 
tion of a speedy cure becomes almost a certainty when the 
female who communicated the disease to the patient suffers 
only from a mucous catarrh of the genital organs, or when the 
disease in the man can be ascribed to the temporary irrita- 
tive influence of the menstrual flow in the woman. The first 
inflammatory gonorrhoeal urethritis of a person is generally 
severer and more obstinate than the following ones of the same 
character. The shorter the intervals between the first inflam- 
matory gonorrhoea and those following, the milder will the lat- 
ter be. The greater the swelling and the eversion of the lips 
of the meatus, the more severe the disease may be expected 
to run. Hemorrhages, peri-urethral inflammatory exudations, 



GONORRHOEA, VENEREAL CATARRH. 31 

infiltrations into one of the spongy bodies, affect the prognosis 
unfavorably. The healing of ulcerations takes a long time, and 
even a mucous catarrh of the deeper part of the urethral canal 
is very slow in getting well. A croupous gonorrhoea causes 
shrinking and contraction of the affected part throughout its 
whole extent. Lastly, hemorrhoidal conditions, scrophulosis, 
and especially pulmonary tuberculosis, tend to delay the cure 
of a gonorrhoea in the male for a long while. 

Prophylaxis against Gonorrhoea, and Treatment of Acute and 
Chronic Gonorrhoea in Men. 

Up to the present day we have not succeeded in finding a 
medicinal agent by the use of which, before or immediately 
after sexual intercourse, a gonorrhoea!, infection may be pre- 
vented. According to Diday's and our own experience, injec- 
tions with a solution of potash considerably diluted, or with 
slightly acidulated preparations, indeed even with pure water, 
directly after coitus, have a decidedly irritating effect; we 
would therefore recommend that such injections be not used 
till the membrum virile has been cooled off in a topical bath of 
cold water. The best security against contracting the disease 
is afforded by the use of the condom, made of various sub- 
stances, such as the intestines of sheep, fish-bladders, and 
India-rubber. Owing to the frequency with which these 
envelopes burst, they can not be relied upon as a sure protec- 
tion. As prophylactic measures which may possibly prevent 
the origin of the disease, the act of coition should be accom- 
plished as quickly as possible, and should not be repeated at 
short intervals ; the individual should abstain from having in- 
tercourse with menstruating women or those suffering from 
lochial discharges, and finally he should urinate directly after 
copulation and wash or bathe the penis in water. 

Inefficient as our measures are to prevent a gonorrhoea, so 
little are we at present able to abort the disease by treatment. 
Injections of caustic preparations — for instance, strong solutions 
of nitrate of silver (1 gramme to 30 of water [= gr. xvj to 
§ j]) before the inflammation has begun to develop, as recom- 
mended by Ricord — may prove positively injurious to the 
patient and never afford any benefit. Indeed, all kinds of 



32 PATHOLOGY AND TREATMENT OF SYPHILIS. 

caustic injections are apt to produce sloughing of the urethral 
mucous membrane, inflammation of the neck of the bladder 
and of the prostate gland, haemorrhage from the urethra, and 
the disease which the physician sought to nip in the bud will 
be vastly protracted and aggravated. In regard to large doses 
of balsamic remedies administered internally, with the object 
of aborting the disease, we hold that they merely give rise to 
severe digestive disturbances, without exercising any beneficial 
effects whatever. 

Hence we are only able to recommend a methodical treat- 
ment of urethral gonorrhoea corresponding to the intensity and 
the stage of the disease. The more intense the inflammatory 
phenomena and the discharge, the milder should the treatment 
be ; the milder the inflammatory symptoms, the more energetic, 
but not too energetic may the treatment be. If the treatment 
adopted consists in the introduction of remedies and medicated 
instruments into the urethra, it is called the direct method ; but 
if a cure is attempted by the action of remedies through the 
digestive and respiratory organs, it is known as the indirect 
method. 

It is of the utmost importance to regulate the diet and 
regimen of the patient. Whether the patient suffers from an 
acute or chronic gonorrhoea, he should be prohibited from 
drinking beer, wine of all kinds, champagne, and soda-water. 
In sensitive individuals these beverages may occasion dysuria, 
bleeding, and other symptoms denoting aggravation ; these un- 
favorable complications are likely to supervene in gonorrhoea, 
even without any special causes. The patient should likewise 
be prohibited from using asparagus, celery, and all other arti- 
cles of diet which stimulate the urinary organs or cause erotic 
sensations. Active exercise, such as running, riding, fencing, 
playing billiards, etc., should be prohibited, and as a measure 
of precaution the patient should be advised to wear a suspensory 
bandage with thigh-straps. Suspensory bandages with elastics 
which press upon the urethra are injurious and should not be 
used. 

Notwithstanding these precautions, the patient is not safe 
from an attack of inflammation of the epididymis. He is, of 
course, to abstain absolutely from sexual intercourse ; a single 



GONORRHCEA, VENEREAL CATARRH. 33 

indulgence at this time is likely to produce the most injurious 
results, and a simple gonorrhoea may become gravely compli- 
cated. The best drink is, after all, pure water ; at the most, 
lemonade in quantities only sufficient to quench the thirst may 
be allowed. Diuretics are directly injurious. In regard to 
his food, the patient should be kept on a spare diet, consisting 
if possible exclusively of vegetables, milk, light tea and mild 
coffee, chocolate, soups, and stewed ripe fruit. If meat has 
to be permitted, it should only be in small quantity and at 
noontime. The patient should eat nothing late in the evening 
or shortly before retiring, in order to avoid seminal emissions. 
Were the gonorrhoeal patients to subject themselves to the 
above-described diet and remain strictly at rest, and in addi- 
tion make daily applications of cold water for several hours to 
the genital organs and peringeum, most cases of gonorrhoea 
would get vjell within four or six weeks without injections or 
internal medicine, or at the most with the aid of very little 
medicine. 

If the patient, in the course of an acute or chronic gonor- 
rhoea, is obliged to urinate frequently, or if blood is ejected 
with the last few drops of the urine, no injection should be 
made into the urethra nor any balsamic remedies administered 
internally. The frequent ischuria and the discharge of blood 
from the urethra or bladder are best relieved by the applica- 
tion of hot fomentations to the region of the bladder and over 
the penis and perinseum, by the introduction of suppositories 
of belladonna or morphine into the rectum, or the internal use 
of both these remedies or of extract of cannabis indica. Iron 
and ergotine may be employed if the haemorrhage continues 
or is severe. For this purpose we prescribe : 

5 Extract, belladonnas (or raorph. raur.), 010 [= grs. jss.] ; 
Butyri de cacao, q. s. ; 
nt. ft. snppositor. parva No. 10. 

5. Three suppositories, well oiled, to be introduced daily into the 
rectum. 

5 Ext. cannabis indica ; 

Ext. semin. hyosciam., aa 0-30 [grs. v] ; 
Sacchar. alba, 3 - 00 [grs. xlvij] ; 
Div. in dosis No. X. 

6. One powder to be taken every four hours. 

3 



34 PATHOLOGY AND TREATMENT OF SYPHILIS. 

^ Liquoris ferri sesquichlor. soluti, 1*50 [gr. xxiij] ; 
Aqua destil., 100*00 [ § iii, 3 ij, 3ij] ; 
Syr. rubi idaei, 20-00 [ § ss., 3iv] ; 
S. One tablespoonful every hour in water. 

3 Carbonatis ferri saccharat. ; 
Ergotini pur, aa 1*00 [gr. xvj] ; 
Sacchar. alba, 3'00 [gr. xlviij] ; 
Div. in dosis No. 10. 
S. Four powders to be taken daily. 

In very intense dysuria and very painful erections, the hy- 
podermic injection of morphia into the perinaeum will afford 
prompt relief. 

[For the control of the ardor urinse, alkalies, such as acetate 
of potash, with spirit of nitri dulcis and camphor-water, may be 
given, diluted in water, every three or four hours. 

In the acute stage, when the chordee is very severe, an 
injection of cocaine before going to bed, and another when 
the patient is attacked by it in the night, have rendered the 
best results. In some cases the cocaine answered admirably 
when all other agents failed.] 

No favorable effects are derived from the internal admin- 
istration of camphor. If the bleeding from the bladder does 
not cease under this treatment, cold-water applications should 
be substituted for the hot fomentations ; but the former should 
be discontinued if they aggravate the pains on micturition. 
If no dysuria be present, and the penis is not much swollen, 
injections may be ordered at once, but if painful urination or 
pain in the testicle ensue, the injections must be immediately 
discontinued, and the remedies above recommended for the 
dysuria, or the measures to be described in the treatment of 
epididymitis, may be resorted to. When no great amount of 
swelling of the penis, in consequence of the inflammation of 
the urethra, is present, injections may be begun. But the 
remedies to be injected must not be too strong or too con- 
centrated ; they should have no escharotic action, nothing more 
than an astringent effect. If the injections employed are of 
the proper strength, the pain from which the patient suffered 
during urination often subsides in from two to three days, and 
the discharge of pus also diminishes, while stronger injections 



GONORRHEA, VENEREAL CATARRH. 35 

quickly aggravate the pains, the penis becomes swollen, fre- 
quent and painful urination and bleeding ensue, and the patient 
is rendered more miserable than ever. As has been remarked 
above, better results are obtained from mild astringent injec- 
tions, employed at proper periods and in a proper manner, 
than from any other measures. And yet many objections have 
been urged against using them. The most serious are that 
by the injections the contagious discharge is forced farther 
backward into the deeper parts of the urethra, and the in- 
flammation is consequently driven into the testes and bladder ; 
furthermore, that astringent or caustic injections accomplish 
nothing more than spasmodic contraction of the sphincter mus- 
cle of the bladder. Now, the contagion can not be forced 
backward, because the injected fluid coagulates the discharge, 
and in that way destroys its infecting properties. The second 
objection is refuted by a thousand-fold experience, which proves 
that the majority of strictures of the urethra are due to those 
morbid changes in the mucous membrane, resulting from per- 
sistent and violent gonorrhceal inflammation alone. We have 
found strictures in patients who for years had suffered from 
gonorrhoea, and submitted to no treatment at all. The ground- 
lessness of the statement that injections may have such an 
injurious effect upon the disease of the urethra as to cause the 
destruction of the epithelial cells of the mucous membrane, 
coagulate the protecting mucus, and corrode the superficial 
layers of the new, imperfectly solidified connective tissue, 
is proved by results obtained in the treatment of gonorrhceal 
disease of the eye, vagina, vulva, and rectum. If we do not 
advocate the abortive method by the aid of caustic agents, and 
concentrated astringent remedies (nay, more, we even urge that 
the greatest caution be exercised in the local treatment with 
astringent preparations), it is not because of the bad effects we 
fear the injections will have upon the mucous membrane, but 
on account of totally different circumstances. If a large quan- 
tity of even the mildest fluid is injected into the urethral canal, 
contracted through inflammation, the mucous membrane of that 
canal will be severely stretched or even torn. Furthermore, 
the sensitiveness of the male urethral mucous membrane, as 
compared with other mucous membranes, should not be lost 



36 PATHOLOGY AND TREATMENT OF SYPHILIS. 

sight of. The mucous membrane of even a healthy urethra is 
markedly irritated by the mere injection of pure cold water. 
Hence an inflamed urethral canal requires to be handled with 
the utmost gentleness. 

The injections are best made with an air-tight but easy-act- 
ing syringe, made either of hard rubber or tin. Glass syringes 
are too fragile and seldom of uniform caliber. It should ter- 
minate in a short, blunt, and smooth end. As air forced into 
the urethra is, apt to produce spasm of the bladder, every parti- 
cle of air should therefore be expelled from the syringe. This 
is best accomplished by turning the nozzle upward and push- 
ing the piston home till the liquid flows out. The amount of 
fluid that may be injected into the urethra should be in pro- 
portion to the length and lumen of that canal. The injection 
may be made with the patient in any position, but it is best 
done when he is standing. The physician grasps the exposed 
glans penis between the thumb, index, and middle finger of 
the left hand; applies closely to the meatus the end of the 
syringe, held between the index and middle fingers of his right 
hand, while with the thumb, inserted in the ring of the piston, 
he slowly presses it home. In patients affected with hypospa- 
dias, and who sometimes have several openings situated behind 
each other — of which only the last is likely to lead into the 
meatus, while the rest terminate blindly — the penis has to be 
twisted upon its axis, so that the meatus, which is situated upon 
its under surface, is made to appear upon its upper surface, 
and the syringe is placed upon it almost perpendicularly. The 
first syringeful may be allowed to come away directly after 
being injected for the purpose of washing away the discharge 
that has accumulated in the canal, and then a second injection 
should be made and retained for a few moments by compress- 
ing the lips of the meatus as the syringe is being withdrawn. 
If the fluid is retained too long, the meatus urinarius is pulled 
and distended too much, and may become greatly irritated. The 
more slowly the fluid is forced into the urethra the more deeply 
will it penetrate. Injections repeated too often are injurious ; 
not often enough, are of little use. We recommend from four 
to six injections daily. For the purpose of ascertaining the 
progress of the urethral affection, and to modify its treatment 



GONORRHCEA, VENEREAL CATARRH. 37 

accordingly, the injected fluid should be allowed to flow into 
a glass vessel from time to time, and the amount of mucus, 
epithelial cells, pus, blood-corpuscles, fibrinous masses, and 
structural detritus it contains, will afford the physician all in- 
dications necessary for that purpose. If the dysuria is aggra- 
vated by the injections, they must be suspended until the 
spasm and pain in urinating are entirely gone. Intense chordee 
and severe urethral haemorrhage likewise contraindicate the 
continuation of injections. In regard to the fluid that should 
be injected, we have been in the habit of using for many years 
a weak solution of permanganate of potash. We begin with 
0*02 of permanganate to 200 grammes [gr. -J to 5 vjss.] of 
water, and gradually increase the strength of the solution, if 
the sensitiveness of the urethra permits, to 0*04 [grs. -§], in the 
same quantity of water. Owing to the readiness with which 
it is decomposed, a sufficient quantity of the medicine, to last 
two or three days only, should be prescribed. In a great many 
cases we succeeded with this remedy in subjugating a purulent 
catarrh in a very few days. If the discharge has already be- 
come mucous, we have recourse to the usual astringent reme- 
dies, such as alum and sulphate of zinc. Of alum, 5*00 to 
250*00 [3iv to § viij] of water is tolerated ; of sulphate of zinc 
or of cadmium, from 0*30 to 0*50 in 200 grammes [grs. 5 to 8 
in 3 vjss.] of water may be used. We generally employ the 
following formula : 

^ Alumin. crudi, 5*00 [3 iv] ; 
Sulph. zinci, 0*50 [grs. viij] ; 
Aqua destil., 250*00 [ § viij]. 
M. To be injected four to five times daily. 

If the mucous membrane is very sensitive the acetates are 
preferable. They may be used in stronger doses. We gen- 
erally order — 

3 Acet. zinei, 0'50 [grs. viij] ; 
Aqua destil., 150*00 [ § v]. 

Or acetate of alum, in the following manner : 

^ Alumin. crudi, 1*50 [grs. xxiij] ; 
Acid, acetic concent., TOO [grs. xvj]; 
Aqua destil., 200-00 [ § vjss.]. 



38 PATHOLOGY AND TREATMENT OF SYPHILIS. 

5 Alurain. crudi ; 

Acet. plumbi basic, aa 1*00 [grs. xvj] ; 
Aqua destil., 200-00 [ § vjss.]. 

If the morbid sensitiveness of the urethra has entirely dis- 
appeared and a weakened condition of the mucous membrane 
of this organ is supposed to exist, alum in combination with 
tannic acid should be tried. We order the following combina- 
tion: 

^ Alum crudi, 1*00 [grs. xvj] ; 
Tannin puri, 0'50 [grs. viij] ; 
Aqua destil., 200-00 [ \ vjss.]. 

If the muco-purulent discharge does not perceptibly dimin- 
ish after using these injections, it may be advisable to resort 
in addition to the indirect treatment and to employ both 
methods. 

If circumscribed infiltrations are present in the corpora 
cavernosa, we order cold water to be applied, and cause the 
infiltrated places to be rubbed with the following ointment : 

Yp Extract, belladonnse, l'OO [grs. xvj]; 
Ung. hydrarg., 10*00 [ 3 ijss.]. 
M. Ft. ung. S. A lump as big as a pea to be rubbed in upon the in- 
filtrated spot. 

As soon as fluctuation is detected, the abscess should be 
opened, in order to avoid the occurrence of urethral fistulse. 

In the treatment of those diseases of the male urethra that 
have been collectively called chronic gonorrhoea, the physician 
must first ascertain the morbid alteration of the urethra that 
keeps up the discharge. These morbid alterations may be a 
markedly relaxed condition of the mucous membrane and 
passive dilatation of the follicles, gonorrhoeal abscesses and 
granular erosions, croupous inflammation, beginning or already 
developed strictures, and the granular and trachomatous con- 
ditions described by Griinfeld. Those practicing endoscopy 
may by that means ascertain the character of the lesion ; up 
to the present date, however, we have not seen any brilliant 
results follow the treatment carried out by means of the endo- 
scopic tube. Those who do not practice it should examine the 
urine which the patient is instructed to pass in a glass vessel, 



GONORRHCEA, VENEREAL CATARRH. 39 

and the injected fluid after it comes out from the urethra. 
To make the examination still more complete, a bougie or 
sound, sufficiently large in caliber, should be passed into the 
urethra ; and, taking into consideration all the circumstances 
present, the physician will be able, jper inductionem et exclu- 
sionem, to diagnose the actual condition of the canal. If he 
has diagnosed the presence of gonorrhoeal ulcerations, he 
should endeavor to prevent the formation of bridle cicatrices 
by the daily introduction of sounds for a long while, and after 
each passage of the sound some astringent should be injected 
into the urethra. In such cases we order nitrate of silver, 
with or without camphor, as in the following formulae : 

3 Argent nitric, 0*20 to 0-50 [grs. iij to viij] ; 

Aqua destil., 200*00 [ 1 vjss.] ; 

Camph. mucil. gum. arab. subact., 0-10 [gr. 1£J. M. 
5 Liq. ferri sesquicblor. soluti, gtt. x ; 

Aq. destil., 200*00 [ § vjss.]. M. 

If we suspect the existence of granulations in the urethral 
canal, we use some insoluble salt or oxide, in the hope of 
causing them to shrink ; for instance : 

3 Magist. bismuth, 5 00 to 10*00 [Biv to viij] ; 

Aq. destil., 200-00 [ | vjss.]. M. 
1$ Zinci sulphas; 

Plumbi acet., aa 1*00 [grs. xvj] ; 

Aqua destil., 200*00 [ § vjss.]. M. 
3 Zinci sulph., 0*50 [grs. viij] ; 

Zinci oxid., 1*50 [grs. xxiij]-, 

Aqua dest., 200*00 [ ^ vjss.]. 
M. Must be well shaken before using. 

If these injections achieve no good result, a bougie, dipped 
in mucilago seminum cydoniorum, or gum-arabic, and after- 
ward in powdered bismuth, may be passed into the urethra 
beyond the granulations. As the greater part of the powder 
is apt to be rubbed off during the introduction of the bougie 
into the urethra, and but little reaches the diseased part, it is 
preferable to introduce the remedies in a solid form, mixed 
with gum-arabic and rolled out into long pencils, like bougies. 
When oiled, these are inserted into the urethra and pushed 
by the aid of a bougie into the membranous portion where the 



40 PATHOLOGY AND TREATMENT OF SYPHILIS. 

disease is most likely to be located. The remedies recom- 
mended above may be prepared for this purpose in the fol- 
lowing manner : 

IJ Zinci sulph., 0'20 [grs. iij] ; 

Butyri de cacao q. s. ut f. bacilli urethrales tenues longitudine 
pollicis No. X. 

One of these sticks, having been pushed into the deeper 
part of the urethra, should be retained there by compressing 
the lips of the meatus; it will soon melt, and exercise its 
healing properties upon the affected parts. The patient should 
be told that, the first time he urinates after the introduction of 
one of these medicated bougies, he is likely to pass a few 
drops of blood. Good results are often obtained in chronic 
gonorrhoea by the introduction of steel sounds of the largest 
size possible into the urethra. In resorting to the use of 
sounds for the purpose of curing this disease, the physician 
should exercise the utmost care, because the forcible introduc- 
tion of hard solid instruments may readily produce false pas- 
sages and the patient be seriously injured. Generally it is quite 
difficult to pass the instrument through the prostatic portion 
of the urethra. To pass this part with the greatest ease it is 
necessary to depress the handle of the instrument till it lies be- 
tween the patient's thighs. The first few times the instru- 
ment is introduced it generally causes severe pains, and the 
operation should therefore be carried out with the utmost gen- 
tleness, and with the patient in a horizontal position. After 
all, a cure will only be achieved by the use of the sounds and 
injections of astringent medicine when there is no urethral 
spasm present. To subjugate this condition, the patient should 
apply warm fomentations to the bladder and penis, and medi- 
cated bougies containing morphia or extract of belladonna 0*01 
(gr. -J) should be pushed into the urethra. After the spasm 
has completely subsided, the use of the sound and injections 
may be again resumed. 

[Of all the injections that have been recommended — and 
I have given them all a thorough trial, both in my clinic and 
private practice — I found none so efficacious as sulphate of 
zinc and belladonna, and now use it almost exclusively : 



GONORRHOEA, VENEREAL CATARRH. 41 

5 Zinci sulph. ; 

Ext. belladonna, aa 0*60 = grs. x; 
Glycerine, 60-00= §ij; 
Aqua, 200-00= I vjss. 
M. S. For injection. 

Recently Dr. Bryant has proposed the irrigation of the 
urethral canal with a solution of corrosive sublimate, 1 to 
40,000 parts of water. More than three years ago I endeav- 
ored to cure a number of cases of gonorrhoea by allowing 
various solutions to flow into the urethra from a fountain- 
syringe through a catheter, but I found the method trou- 
blesome, without deriving an equal amount of benefit 
from it. 

In protracted cases in which the deeper parts of the urethra 
are involved, and the acute inflammatory symptoms have en- 
tirely subsided, I cause deep urethral injections to be made 
with a long-nozzle syringe, or use Mitchell's medicated bou- 
gies. The latter, however, are not always tolerated, for they 
act as foreign bodies, and the pain they occasion does not sub- 
side till the melted ingredients of which they are composed 
have been ejected. In these cases I have very often succeeded 
in effecting a cure by making applications of a two-per-cent 
solution of nitrate of silver through an endoscopic tube with 
a fine brush. Having first ascertained the exact location of 
the affected part by means of conical probes, the tube is in- 
serted, pushed in so far that its internal end touches the dis- 
eased part, and then the solution is applied.] 

The use of cool sitz-baths is of material service when 
combined with the local treatment. In some cases it is useful 
to combine the local with the internal treatment by means of 
the ethereal-balsamic remedies, especially in those cases in 
which the local measures already recommended have been 
faithfully tried without accomplishing any good results, par- 
ticularly if no contraindications, such as digestive disturbances, 
are present. Lastly, attention should be paid to the possible 
presence of hsemorrhoids, hyperemia of the rectum, irritation 
of this organ by ascaridis, ansemia, scrofula, etc. These re- 
quire appropriate treatment before a successful result can be 
attained in obstinate cases of chronic gonorrhoea. 



42 PATHOLOGY AND TREATMENT OF SYPHILIS. 

The Indirect or Internal Treatment of Gonorrhoea of the Male 

Urethra. 

The indirect or internal treatment consists in the employ- 
ment of certain remedies, which when introduced into the sys- 
tem are in greater part excreted by the kidneys, then pass 
with the urine through the urinary apparatus, and exercise in 
this manner a curative effect upon the diseased mucous mem- 
brane. This also explains the reason why these remedies are 
only effective in gonorrhoea of the male and female urethra, 
and not in gonorrhoea of the vagina and uterine canal, and 
have little or no curative properties in gonorrhoea of the eyes 
and rectum. These remedies may be introduced into the sys- 
tem either through the digestive or the respiratory organs — 
possibly also by a prolonged application upon the integument. 
Among these are the following remedies : Copaiba, balsam of 
Peru and Tolu, turpentine,, cubebs, ol. santal. flava, the so- 
called wood-oil, or gurgon balsam, and, lastly, certain prepara- 
tions of matico. 

Up to the present time balsam of copaiba has remained the 
favorite remedy. Its unpleasant taste, however, is a great 
hindrance to its administration, and many ways have been de- 
vised of disguising it. The best is by inclosing it in gelatine 
capsules ; each capsule usually contains from six to seven drops 
of copaiba (capsules de Mothes et de Eaquin). Others give 
balsam of copaiba in aromatic tincture, or in the form of pills 
(copaihine Mege of the French). If it is desired to administer 
it in its purity, it should be ordered to be taken three or four 
times daily, fifteen to twenty drops each time, on a lump of 
sugar, or in some liquor prepared as follows : 

^ Tinct. aromat. acid., 5*00 [Biv] ; 
Balsam copaiba, 20-00 [f ss., 3iv]. 
M. S. Fifteen to twenty drops to be taken four times daily. 

For the purpose of administering it in pills, it is best com- 
bined with magnesia. Thus we order : 

5 Bals. copaiba, 10-00 [ 3 ij, 3ij] ; 

Mag. ust. q. s. ut form. pil. pond., 0*30 [grs. v]. 
S. Six to eight pills to be taken four times daily. 



GONORRHOEA, VENEREAL CATARRH. 43 

Or, the balsam of copaiba, made in pills and wrapped in 
wax, as in the following formula : 

^ Ceraa albaa, 5 -00 [9iv]; 
Adde: Bals. copaiba, 10*00 [3viij]; 

Pulv. magnes. q. s. ut ft. massa pilul. forment pilul. 
pond., 0*30 [grs. v], consp. pulv. eodem. 
S. Eight pills to be taken three times daily. 

[The following are excellent formulae for administering co- 
paiba in emulsions or pills. These combinations are better 
tolerated and less objectionable on account of their disagree- 
able taste, and very efficacious : 

3 Copaiba, 30-00 = |j; 
Liq. potasssB, 4 - 00 = 3 j ; 
Ext. glycyrrhizse, 15-00 = § ss. ; 
Spt. setheris nitrici, 30-00 = § j ; 
Olei gaultherise, gtt. xvj. 
Mix the copaiba and the liquor potassao and the ext. of liquorice and 
spirits of nitre first separately, and then add the other ingredients. 
(Bumstead.) 
S. A tablespoonful after each meal. 
B Copaibao, 60-00 = I ij ; 
Magnes. carb., 2*00 = 3 ss.; 
01. menthse pip., gtt. xx ; 
Pulv. cubebas; 

Bismuth subnitratis, aa 60-00 = 1 ij. 
M. To be divided in pills of 0*3 grs. v each, and coated with sngar. 

In this prescription the cubebs serves as a stomachic ; the 
alkali and the bismuth are also good anti-dyspeptic remedies.] 

Balsam of Tolu is met with in commerce as an inspissated, 
resinous substance, which, before using, must be dissolved in 
spirits of wine. It has no unpleasant taste, but as a remedy 
is inferior to the other resinoids used in the cure of this 



The black Peruvian balsam is administered in the same 
manner, and in similar doses, but is seldom used, on account of 
possessing little medicinal virtue. 

The therapeutic properties of oil of turpentine are almost 
as great as those of balsam of copaiba, but this oil is even 
more unpleasant than any of the remedies already spoken of. 



44 PATHOLOGY AND TREATMENT OF SYPHILIS. 

It is best administered in pill form, generally combined with 
an astringent or iron : 

5 Zinci sulphas puri ; 

Terebinth, laricis, aa 1 00 [grs. xvj] ; 

Pulv. rad. ratanhiaa q. s. 
M. Ut ft. pil. No. 30, consp. pulv. cinnamonri. 
S. One pill three times daily. 

^ Ferri sulph., 5'00 [3iv] ; 

Terebinth, laricis, 2*00 [grs. xxxj] ; 

Pulv. lycopod. q. s. u. f. pil. pond., 0*20 [grs. iij], consp. pulv. 
cinnamomi. 
S. Five pills to be taken three or four times a day. 

Cubebs, piper caudatum, may be administered either in 
powder or pill form ; for the latter, the ethereal extract or 
freshly powdered berry is well adapted. The following for- 
mulas may be used : 

^ Pulv. piper cubebias recent., 20'00 [§ ss., Biv] ; 
Sacchar. lactis, 5*00 [3iv]. 
M. S. Divide in doses equale No. 12. To be put in capsules, and 
taken in forty -eight hours. 

1£ Pulv. piper cubebiso recent, 20*00 [§ ss., Biv] ; 
Ext. juniper ; 

Syr. simplex, aa, 50'00 [ 1 jss., 3iv]. 
M. S. To be taken in twenty-four hours. 

If a cure is to be achieved by means of cubebs, the patient 
will have to take from 13*00 to 15*00 grammes [ 3 iijss. to 3 iv] 
of the remedy in twenty-four hours. 

Grimault, of Paris, has introduced the use of the so-called 
matico capsules. They contain an ethereal oil, prepared from 
the leaves of the drug matico, piper angustifolium or elonga- 
tum, extract of cubebs, and balsam of copaiba. We never 
succeeded in effecting a cure by the administration of matico- 
oil alone, but we did with matico capsules. The latter are 
preferable to the copaiba capsules, in so far as they are better 
tolerated, owing probably to the oil of matico, which seems to 
act as a stomachic. Of these matico capsules, from nine to fif- 
teen should be taken daily. The so-called " injection vegetal," 
made of matico, arid known under that name in commerce, 
contains ethereal oil of matico and sulphate of copper. 



GONORRHCEA, VENEREAL CATARRH. 45 

Now, experience has shown that many persons suffer from 
vomiting and diarrhoea as the result of the internal administra- 
tion of the antiblennorrhoaa-balsamic remedies, and in others a 
prolonged use of these remedies will occasion chronic gastric 
and intestinal catarrh. But the injurious effects produced upon 
the digestive organs are not the only evils occasioned by them. 
In some patients they also give rise to a peculiar eruption of 
the skin. Attended by gastric and febrile disturbances, groups 
of pale, wheal-like eruptions develop about the wrists, hip- 
joints, and especially on the face. They resemble nettle-rash 
very closely, and, like the latter, cause severe burning and itch- 
ing, especially when the patients get warm in bed. This affec- 
tion of the skin is called urticaria balsa7nica, and, owing to its 
resemblance to roseola syphilitica, was until quite recently re- 
garded by some physicians — Cazenave, for instance — as proof 
that gonorrhoea was the initial disease of syphilis. That this 
assertion is incorrect is. proved by the fact that the eruption 
disappears as soon as the use of the remedy is discontinued. 

It is also asserted that the ethereal- balsamic remedies exer- 
cise an injurious effect upon the kidneys, in consequence of 
which Bright's disease is said to result. Now, if to the urine of 
a person who several hours previously had taken cubebs, co- 
paiba, or turpentine-oil, some strong mineral acid is added, an 
opalescent, gelatinous sediment is precipitated which might be 
readily mistaken for coagulated albumen, but it is distinguished 
from the latter by the fact that it again becomes soluble on boil- 
ing, or on the addition of alcohol, carbonate of potash, or am- 
monia. The researches of Berzelius and Johnson have shown 
that the constituent elements of the balsamic remedies are an 
ethereal oil and a resinous acid. The experiments of Drs. 
Weikart and H. Zeissl have proved that the precipitate above 
alluded to is not due to the ethereal oil. Consequently, we can 
explain its production by the following theory : The resinous 
acids are the vehicles containing the curative principles ; in the 
intestines or blood they combine with the potash or the soda 
and form a soluble resinous soap in the excreted urine — a resin- 
oid potash or soda. If to such urine a stronger acid than the 
resinous acid is added, for instance, nitric acid, the resinous 
acid that is insoluble in water is precipitated as a whitish sedi- 



46 PATHOLOGY AND TREATMENT OF SYPHILIS. 

ment. Prof. H. Zeissl and Dr. "Weikart sought to make 
therapeutical use of the transformation which the resinous acid 
undergoes in the urine, by administering resinous acid alone or 
resinous soap to patients suffering from gonorrhoea. And they 
actually succeeded by this means in reducing the blennorrhoic 
discharge to the least possible quantity, and by a prolonged use 
of the remedy in suppressing it entirely. But no sediment, 
or at the most a feeble whitish cloudiness, was seen in the 
urine ; to produce even that, large quantities of the drug had 
to be administered. Hence it seems that the resinous acids, 
in their natural combination with the ethereal oils, pass out 
in the urine more quickly than isolated pure or saponified res- 
inous acids. It can not be maintained, however, that the 
ethereal oils of the balsams mentioned here are excreted from 
the system without producing any effect, because clinical ex- 
perience has shown that, when introduced into the system 
by inhalation, they accomplish some good results in urethritis 
and pyelitis. Dr. Bremond, Jr., claims to have obtained better 
effects from turpentine- vapor baths than from inhalations. 

Catarrh of the Glans Penis and Prepuce, Balanitis, Balance 
Blennorrhea, Balanopyorrhcea, Balanopostheitis. 

The sebaceous glands, glandulse Tysonii, situated in the 
fossa glandis and on the inner surface of the prepuce, secrete 
so large a quantity of sebum in some persons that it undergoes 
decomposition — especially when allowed to accumulate, and in 
those whose habits are uncleanly — and irritates the parts. 
These become inflamed and produce a profuse discharge. This 
follicular hypersecretion may be produced by friction of the 
secreting surfaces — for instance, in masturbators (especially 
when the preputial orifice is constricted) — by gonorrheal pus, 
or chancrous discharges, warts, syphilitic initial indurations, 
syphilitic mucous patches or eruptions on the glans penis and 
mucous membrane lining the prepuce, and epithelial carcinoma. 

Catarrhal disease of the glans and prepuce manifests itself 
by an itching sensation which gives rise to erections. Gradu- 
ally the tickling sensation becomes transformed into a painful 
feeling. The glans and the prepuce become oedematous ; the 
external surface of the latter becomes red and erysipelatous ; a 



GONORRHCEA, VENEREAL CATARRH. 47 

profuse discharge wells up from the preputial orifice which 
has the odor of boiled carpeuter's-glue. "When neglected, 
erosions and even ulcers originate on the inner surface of the 
prepuce and on the glans penis ; the discharge becomes green- 
ish in color and purulent (pyorrhoea). The lymphatic vessels, 
situated on the dorsum of the penis, the superficial and deep 
inguinal glands become inflamed ; phimosis and paraphimosis 
may result ; indeed, it is even possible, especially when a chan- 
cre is present on the inner surface of the prepuce, that the 
latter, as well as the glans, will, in consequence of constant 
pressure or constriction, become gangrenous. Condylomata 
and vegetations are another result of catarrh of the prepuce 
and glans penis. In extreme cases balanitis, when associated 
with phimosis, may terminate in limited or extensive synechia 
between the glans and prepuce, rendering sexual intercourse 
exceedingly painful in consequence of the traction between 
the parts. 

Phimosis and Paraphimosis. 

Under the term " phimosis " we understand an abnormal 
constriction of the prepuce to such an extent as to make it im- 
possible to expose the glans fully. In some cases the prepuce 
can only be retracted sufficiently to expose the tip of the glans 
penis. The cause of phimosis is the disproportion between the 
size of the prepuce and that of the glans penis. This kind of 
phimosis is called temporary, in contradistinction from the per* 
manent or congenital phimosis. The latter condition is due to 
the structure of the prepuce, which, being too long, forms a 
funnel-like cap over the glans ; the preputial orifice is there- 
fore narrower than in persons in whom tins funnel-like cover- 
ing is shorter and more widely expanded. Again, if the frse- 
num extends up to the urethral orifice, it is difficult to retract 
the prepuce, and if force is used the frsenum will be dragged 
backward and the glans penis downward ; the former is often 
torn and the wound bleeds. Such long and narrow prepuces 
are usually traversed by large varicose veins, whose compres- 
sion during the existence of a balanitis will often occasion 
oedema. 

If a phimotic prepuce is forcibly retracted over the glans 



48 PATHOLOGY AND TREATMENT OF SYPHILIS. 

penis, there results the condition known as paraphimosis. The 
preputial opening that is now drawn backward behind the 
corona glandis constricts it and causes it to swell up. The re- 
turn flow of blood from the glans is impeded, while the sup- 
ply is not retarded. In consequence of this, the glans swells 
still more ; a serous exudation takes place in that part of the 
prepuce anterior to the constricting point, whereby a semi- 
lunar swelling forms on the lower border of the corona glan- 
dis, which overlaps the constricting point — a condition that 
has been called the " Spanish collar.' ' Under unfavorable cir- 
cumstances the constricted parts may even become gangrenous. 

Differential Diagnosis and Treatment of Catarrh of the Glans 
Penis and of the resulting Inflammatory Phimosis and Para- 
phimosis. 

Balanitis with coexisting phimosis may be mistaken for 
gonorrhoea of the urethra. The diagnosis can only be based 
upon the course of the disease. The erosions upon the glans 
penis and internal surface of the prepuce produced by bala- 
nitis sometimes are ' not easy to distinguish from superficial 
chancroids, initial syphilitic lesions, and their consecutive phe- 
nomena. The chancroid ulcers, owing to their great tendency 
to inoculate, give rise to numerous deep, sharply outlined small 
sores ; thus we often have follicular ulcerations in the fossa 
glandis, and deep ulcers occasionally on the frsenum. In cases 
complicated with phimosis the existence of chancroids or 
chancres can only be ascertained by inoculation and the course 
of the disease. If the discharge exuding from the preputial 
orifice is mixed with chancrous virus, the inoculations will 
produce pustules after a longer or shorter period of incubation, 
according to the nature of the virus, and the pustules exhibit 
a tendency to run into ulcerations. Under appropriate treat- 
ment simple erosions heal in a few days, sometimes even in a 
few hours. They are distinguished from syphilitic initial le- 
sions by the total absence of induration or parchment-like hard- 
ness beneath them, while erosions which have arisen from ex- 
coriations of the efflorescences of roseola syphilitica are accom- 
panied by spots on the body, indolent glandular swellings, etc. 

In mild forms of balano-blennorrhoea, frequent cleansing 



GONORRHOSA, VENEREAL CATARRH. 49 

of the glans and prepuce, and keeping these parts from coming 
in contact with each other by interposing bits of clean muslin, 
or a thin layer of cotton-wool, will suffice to effect a cure. The 
prof ase secretion may be quickly suppressed by the application 
of a strong lead-lotion four or five times a day, or an injection 
of nitrate of silver 0*10 or O20 to 50-00 [If to 3£ grs. to g jss. 
of water]. After the injection, compresses dipped in the solu- 
tion may be applied between the glans and prepuce. If it is 
suspected that there are erosions or ulcers on the glans and 
internal surface of the prepuce, a long stick of nitrate of silver 
should be inserted under the prepuce, and by a rapid move- 
ment the glans and prepuce are to be cauterized. In addition, 
the injections with the above preparation should be continued. 
If the febrile phenomena, the pain and swelling, are severe, 
and gangrenous sloughing is apprehended, the patient will have 
to go to bed ; the penis should be kept elevated, or fixed on 
the abdomen, and ice applied to it. If the danger from gan- 
grene does not abate, the constricted prepuce should be split, 
or circumcised. The latter, in our opinion, is the more appro- 
priate treatment. 

Splitting of the prepuce may be done in two ways. Either 
both layers of the skin are divided at once in the median 
line or the internal layer alone, the mucous membrane, is in- 
cised. The first method, which we resort to in congenital as 
well as in acquired inflammatory phimosis of moderate degree 
(where the prepuce is not very long), consists in retracting the 
foreskin as much as possible to the corona glandis, and passing 
a grooved director beneath the prepuce. Upon this one blade 
of a straight scissors is passed, and both lamellae are divided at 
once in the median hue of the dorsum of the penis to an ex- 
tent of about one to one and a half centimetre. The slight 
haemorrhage that follows is arrested by a few stitches inserted 
in the lips of the wound, and lead-water dressings are applied 
to the parts. 

The second method we employ in those cases of aggravated 
congenital phimosis in which markedly dilated veins anasto- 
mose in the foreskin. The prepuce is retracted as much as 
possible, so that the margin of its inner layer is exposed, and 
it is then snipped with a delicate pair of scissors to the extent 
4 



50 PATHOLOGY AND TREATMENT OF SYPHILIS. 

of two to four millimetres. This incision allows the foreskin 
to be retracted a little more, and an additional portion of the 
inner layer can now be exposed. With the points of the scissors 
the first incision is extended, snipping the mncons membrane 
only little by little, as the prepuce itself is being retracted grad- 
ually over the glans penis till the latter is finally entirely ex- 
posed. After this has been accomplished the bleeding is 
arrested, cold water dressings are applied to the glans, and the 
prepuce is restored to its normal position. Fresh pledgets of 
linen or cotton-wool must be inserted several times daily till 
the incised wound has completely cicatrized. 

Circumcision is indicated in those cases in which, in conse- 
quence of the accumulation of ichorous discharges, gangrene of 
the foreskin, or of the glans, or of both is imminent, or has already 
commenced. The operation is performed as follows : An as- 
sistant holds the penis of the patient (who lies on his back) in 
his left hand, and with the thumb and forefinger of his right 
hand draws back the foreskin as far as possible toward the co- 
rona. The operator then inserts a grooved director between 
the prepuce and glans, assures himself by sweeping the glans 
with the instrument that it did not pass into the urethra, car- 
ries it in the median line on the dorsum of the glans with the 
grooved surface facing upward as far as the fossa, and divides 
both layers of the skin either with a scissors or a sharp-pointed 
bistoury up to the fossa glandis. The flaps of the skin result- 
ing from the incision are amputated by the aid of a curved 
pair of scissors, with its concave surface directed toward the 
glans, following the course of the corona to the frsenum, taking 
care not to injure the corpora cavernosa or divide the arterial 
branches coursing in the frsenum. It is necessary to preserve 
the frsenum, because as a result of its division the integument 
of the penis loses its point of fixation, and the margins of the 
wound are liable to become displaced. Bleeding vessels should 
be tied or twisted ; the slight bleeding, however, is generally 
arrested by sewing up the wound. The operation may also be 
performed with the aid of Esmarch's bandage. Adhesions be- 
tween the glans and prepuce should be divided with the scis- 
sors. [This operation may be rendered perfectly painless by 
the use of cocaine, either by injecting a four-per-cent solution 



GONORRHCEA, VENEREAL CATARRH. 51 

of the muriate of cocaine subcutaneously or simply brushing 
the skin and mucous membrane of the prepuce a number of 
times with it. In about five or ten minutes the skin will be 
found to have lost all sensibility, when it may be amputated 
and the stitches inserted without causing the patient any pain.] 
Paraphimosis calls for the reduction of the constricted 
glans as soon as possible. This operation may be carried out 
in the following manner : The physician places both his 
thumbs upon the glans of the patient, thereby compressing it 
laterally and at the same time pressing it backward, while with 
his index-fingers above and the middle fingers below the penis 
he endeavors to push the preputial welt forward over the co- 
rona glandis. If it be no longer possible to replace the fore- 
skin, the constricting welt should be divided with a sharp- 
pointed bistoury upon a grooved director inserted beneath the 
ring in the median line of the dorsum of the penis, after which 
the prepuce may be .brought down to its normal position. If 
the paraphimosis, however, has already existed for several 
days, it will be impossible to reduce the displaced prepuce; 
it will then be necessary to divide the collar-like welt with 
two circular and parallel incisions, and, sparing the corpora 
cavernosa, the strip of constricting band may be dissected out 
from the welt alluded to. The edges of the wound should be 
united with sutures. 

Affections of the Lymphatic Vessels and Glands in consequence 
of Gonorrhoea. 

Acute and chronic urethral gonorrhoea occasionally give 
rise to inflammatory swelling of the lymphatic vessels of the 
dorsum of the penis and of the lymphatic glands of the groin. 
The inflammation of the lymphatic vessels manifests itself by 
one or two smooth or nodular cords, as thick as the quill of a 
raven, running from the fossa glandis to the mons veneris, and 
by a linear oedematous, erythematous swelling of the skin. 
Pressure on the affected tracts, or pinching up a fold in the 
skin, causes marked pain. Owing to the swelling of these 
lymphatic vessels, the pain during erections is also aggravat- 
ed, and for that reason the organ is frequently curved toward 
the pubis. Under appropriate treatment inflammation of the 



52 PATHOLOGY AND TREATMENT OF SYPHILIS. 

lymphatic vessels as a result of gonorrhoea disappears in the 
course of twelve or fourteen days. 

The lymphatic glands of the inguinal region are less fre- 
quently affected in consequence of gonorrhoea than the lym- 
phatic vessels. In the majority of cases resolution takes place 
in these inflamed inguinal glands ; but, in debilitated persons, 
or those afflicted with the tuberculous or scrofulous cachexia, the 
glands will undergo suppuration. The treatment of inflamma- 
tion of the lymphatic vessels and glands, in most cases, is lim- 
ited to the application of cooling lotions, since suppuration sel- 
dom ensues. In intense inflammation of the lymphatic vessels, 
inunctions of ung. hydrarg., in quantities of about the size of a 
pea twice daily in the course of the affected vessel, are of great 
benefit. 

Inflammation of the Vasa Beferentia And the Epididymis. 

The most frequent sequela produced by urethral gonorrhoea 
in the male is inflammation of one of the vasa deferentia 
and epididymis. Like pharyngeal catarrh of the mucous 
membrane traveling downward and attacking the larynx, 
trachea, and bronchi, so the catarrhal affection of the pros- 
tatic portion of the urethra not infrequently extends to the 
vasa deferentia and epididymis. The affection of these or- 
gans, consequently, is not to be looked upon as a metastasis, 
i.e., as a leap of the catarrhal affection from the urethral 
tract to the testis, but it originates through contiguity — in 
other words, the catarrhal process travels on from cell to cell, 
and as soon as it has reached the vicinity of the caput gallina- 
ginis — which usually occurs in the third week of a gonorrhceal 
disease — there is a possibility of the affection of a vas deferens 
with its corresponding epididymis. It is a wonder that the 
parts mentioned do not become affected in all cases of catar- 
rhal inflammation of the prostatic urethra, and, furthermore, 
that even in the most pronounced cases of inflammation of the 
epididymis the simultaneous implication of the vas deferens is 
not always apparent. This last condition, after all, has its 
analogy in the pathogeny of buboes that undergo resolution, 
and which originate, in the majority of cases, without any ap- 
parent inflammation of the lymphatic vessels. As a rule, how- 



GONORRHCEA, VENEREAL CATARRH. 53 

ever, in epididymitis in consequence of gonorrhoea, there is 
found an inflammatory thickening of the corresponding vas 
deferens or spermatic cord, and seldom is a vas deferens af- 
fected without the coincident disease of the epididymis. 

In inflammatory affections of the vas deferens the patients 
complain of severe pains in the vicinity of the abdominal riug, 
through which the affected spermatic cord passes into the in- 
guinal canal. The pain spoken of becomes aggravated on 
touching the cord, the latter being readily felt as a dense, 
hard, round string, like a goose-quill. The loose connective 
tissue of the tunica vaginalis communis and the adjacent sub- 
cutaneous connective tissue of the scrotum become infiltrated 
with serum, and swollen. General disturbances of the system 
soon supervene. As in epididymitis, the patients complain of 
chilliness and a feeling of heaviness in the head ; the pulse 
becomes quickened, the temperature of the skin elevated. 2s ot 
infrequently nausea, and even vomiting come on ; usually an 
obstinate constipation is present (circumscribed peritonitis). 
In rare cases suppuration of the thickened spermatic cord may 
follow. 

The subjective symptoms of epididymitis usually come on 
suddenly. The patients claim to have felt at the beginning 
of the disease a sensation as if a drop of hot liquid had dropped 
into the affected scrotum. Soon after the affected testis ap- 
pears to them to have become markedly heavier and walking 
is irksome. During the first three days the diseased epididymis 
is felt as a doughy mass at the inferior part of the posterior 
scrotal wall. On the third or fourth day the swelling of the 
epididymis becomes more tense, and the organ usually descends 
still lower. In this manner a twisting of the axis of the testi- 
cle upon its transverse diameter takes place. We have likewise 
had the opportunity of confirming Dr. Bergh's observation, 
namely, that in some cases a twisting of the axis of the testicle 
upon its longitudinal diameter takes place, the epididymis ap- 
pearing at the anterior instead of at the posterior border of 
the testis. In the progress of the disease the testis itself 
swells up, sometimes attaining the size of a fist ; the increase 
in size, however, is not due to swelling of the parenchyma of 
the testicle, but to serous effusion into the tunica vaginalis 



54: PATHOLOGY AND TREATMENT OF SYPHILIS. 

propria (acute hydrocele). Finally, there also occurs a serous 
infiltration into the loose cellular tissue of the scrotal integu- 
ment ; its wrinkles become effaced, and it acquires a bright- 
red color (erythma glabrum). These phenomena indicate that 
the epididymitis has attained its height, in which condition it 
usually remains for five or six days. On the tenth day of the 
disease, resolution begins, ushered in by febrile exacerbation, 
and the effusion into the subscrotal connective tissue and into 
the tunica vaginalis propria begins to be absorbed. The sub- 
jective and objective symptoms gradually disappear, so that 
the disease generally terminates by the beginning of the third 
week, leaving no trace behind it, save a painless hardness of 
the epididymis consequent upon hypertrophy of its connective 
tissue. This hardness generally does not interfere with the 
functions of the testicle ; occasionally it is liable to cause a 
temporary and even permanent impotence. In many grave 
cases of inflammation of the epididymis and of the vas deferens 
the semen undergoes morbid changes to such a degree as to be- 
come bloody when pollutions ensue (spermatorrhoea cruenta). 
In cases of bloody semen, the spermatozoa generally are totally 
absent. Occasionally, even after the termination of an epidid- 
ymitis, the semen for some time has a rusty color, due to the 
admixture of blood. Atrophy of the testicle as a result of 
epididymitis blennorrhagia we have seldom seen, and then only 
in those cases in which Frick's compressed bandage was ap- 
plied too energetically and for too long a time. 

In very rare cases a cheesy degeneration and necrotic dis- 
organization take place in the diseased epididymis, or in the 
surrounding tissues, without any coexisting tuberculosis in the 
lungs, prostate gland, or kidneys. Cheesy foci form, break 
through the tunica vaginalis and scrotal integument, and dis- 
charge a crumbling, cheesy pus. The borders of the perfora- 
tions in the scrotal integument then become agglutinated di- 
rectly with the exposed tunica albuginea, from which extensive 
exuberations of connective tissue are occasionally protruded, 
constituting a " fungus benignus." "Wendelin saw an epididy- 
mitis originate in a patient with chronic urethritis, which be- 
came associated with marked swelling of the funiculus and 
secondary peripheral inflammation, attacking the peritonaeum, 



GONORRHCEA, VENEREAL CATARRH. 55 

going on to suppuration and perforation of the bladder and 
rectum. The case terminated fatally; no autopsy, however, 
was made. 

Another equally rare result of epididymitis is neuralgia, 
whose site can not be more explicitly described than that it 
is in the course of the pudendal plexus of nerves. This 
tortures the patients to such a degree that some of them, as 
reported by Michaelis, demand the operation of castration. 
The most frequent evil effects of epididymitis are the accu- 
mulation of fluid in the sac of the tunica vaginalis propria, 
known by the name of " hydrocele chronica." 

Inflammation of the spermatic cord and of the epididymis 
in consequence of urethral gonorrhoea is generally unilateral. 
One epididymis is as often affected as the other, but not both 
simultaneously. The disease in one generally comes entirely 
to an end before the other is attacked, and in such cases the 
left testis is always the one first affected. 

Although epididymitis terminates favorably in most cases, 
still in some fistulse form in the scrotum, and still more often 
a permanent accumulation of serum in the tunica propria en- 
sues. We have, moreover, observed that persons who have 
suffered from repeated attacks of epididymitis blennorrhagica, 
if they subsequently acquire syphilis, readily become affected 
with albuginitis syphilitica. 

The following painful lesion of the testis may be mistaken 
for a beginning epididymitis: There are certain, individuals 
who on becoming sexually excited, and without having an 
emission of semen, suffer such intense pain in the testicle at the 
slightest touch, and even without touching it, that the pain 
will cause them to faint. The absence of swelling in the vas 
deferens and in the corresponding epididymis, the statement 
of the preceding excitement, and, lastly, the exceedingly favor- 
able effect which the application of cold compresses produces 
in a few minutes, will show conclusively the true nature of 
the complaint. 

An epididymitis in cryptorchids may be mistaken for her- 
nia or swelling of the inguinal glands. But the absence of the 
testicle from the scrotum will guide the physician to a correct 
diagnosis. The differential diagnosis between blennorrhoic 



56 PATHOLOGY AND TREATMENT OF SYPHILIS. 

epididymitis and an epididymis resulting from syphilis will be 
elucidated in the section on syphilitic disease of the testicle. 

Finally, we wish to say a word concerning an exceedingly 
rare morbid alteration of the testicle, which Yon Foerster has 
described under the name of chronic epididymitis terminating 
in atheromatous degeneration, and which may readily be mis- 
taken for gonorrhoeal epididymitis. In this lesion the testicle 
enlarges gradually, without any febrile phenomena, and the 
pain is not severe. Subsequently, the pain disappears entirely, 
while the enlargement remains stationary, and the only change 
noticeable in the testicle is that it becomes doughy. If such a 
testis is examined after death an atheromatous substance con- 
taining numerous crystals of cholesterine and liquid drops of 
oil may be pressed out of it. 

Treatment of Inflammation of the Spermatic Cord and Epi- 
didymis. 

The treatment of inflammation of the spermatic cord and 
epididymis does not vary very much. The main indication is 
to alleviate the pain, and to limit the inflammation and its effects 
as much as possible. We have seen the pain most quickly 
subjugated by the application of Horand's (Lyons) dressing, 
which we have modified. The dressing consists of three parts : 
(1) a sufficiently thick layer of wadding ; (2) a square piece of 
India-rubber cloth ; and (3) a muslin suspensory. The latter 
has a triangular, slightly concave shape, and at its upper mar- 
gin a hole is cut, through which the penis is passed. Its upper 
corners are provided with two long bands, or, better still, a 
belt may be used, with a buckle for the purpose of securing 
it around the abdomen. At its lower angle two thigh-straps 
or bands are fastened, which may be tied either to the buckles 
of the belt or drawn through the bands passing around the ab- 
domen, and tied to them. The lateral borders of the suspen- 
sory are incised, and each cut is provided with two short tapes. 
The apparatus is best applied when the patient is in the recum- 
bent position. The patient draws up the genital organs as 
high as possible against the symphysis pubis ; the entire scrotum 
is then covered with a layer of wadding ; the square piece of 
India-rubber cloth with a circular hole near its upper border 



GONORRHCEA, VENEREAL CATARRH. 57 

through which the penis is passed is next placed upon the 
wadding, with the glossy surface directed toward it, and upon 
that the triangular piece of muslin. Finally, the belt is buckled, 
or the belly-band alluded to is tied around the waist ; next, the 
thigh-straps or thigh-tapes are made fast to the belt or belly- 
band ; and, lastly, the tapes at the side-cuts are tied over the 
dorsum of the penis as tightly as possible. By the aid of this 
apparatus the scrotum can be raised up nearly to the symphy- 
sis, and the pains disappear almost immediately after it is ap- 
plied, enabling the patient to pursue his calling. The epidid- 
ymitis is generally cured in about eight or ten days. If not, 
the apparatus may be retained for a longer period. Should 
the epididjmiitis be complicated with an acute hydrocele or in- 
flammation of the spermatic cord, the apparatus alone will not 
be sufficient to relieve the pain. If the pains are not relieved, 
or the patient has fever, he will have to go to bed, and the 
scrotum should be suspended in a towel as high as possible, or 
elevated by a pillow rolled up and placed between the thighs. 
Cold or cooling lotions may then be applied to the inflamed 
testicle. Xo ice-cold applications should be made, especially 
in tuberculous persons, in whom haemoptysis has been known 
to occur under this treatment. Some authors also claim to 
have seen gangrene of the scrotum produced by the applica- 
tion of ice. Compresses dipped in cold water or in lead-water 
are amply sufficient. For the relief of the pain, ung. bella- 
donnas, composed of extr. belladonna 5'00 (3 iv) and ung. 
iitharg. 20 '00 ( 3 v), may be rubbed in upon the scrotum. Xo 
mercurial ointment should be applied upon the scrotum, for it 
is apt to occasion a violent eczematous eruption and intense 
pain. If the pain is veiy great, morphia may be injected sub- 
cutaneously in the inguinal region. It is of the utmost im- 
portance in the treatment of epididymitis that the patient 
should have daily movement of his bowels. It is scarcely 
necessary to say that, upon the onset of an epididymitis, injec- 
tions into the urethra and the internal administration of bal- 
samic remedies must be immediately discontinued. 

There is another method recommended by Dr. Fricke, of 
Hamburg, for the purpose of causing the absorption of the 
effused fluid into the tunica vaginalis. This consists of strap- 



58 PATHOLOGY AND TREATMENT OF SYPHILIS. 

ping the scrotum with strips of adhesive plaster. The strips 
should be half a metre (19 inches) in length and eight to ten 
millimetres (about an inch) in width. Before strapping the 
scrotum it and the pubis should be shaved. The physician 
now pushes the sound testis up toward its inguinal ring, al- 
lowing the patient or an assistant to hold it there. He next 
grasps the diseased testicle in his left hand, brings the long- 
est diameter of the scrotum in a line with the longest diame- 
ter of the affected testis, then encircles the upper part of the 
scrotum with a strip of adhesive plaster. Each subsequent 
strip of plaster is made to overlap the preceding one like shin- 
gles on a roof. Three or four longitudinal strips are laid upon 
the scrotum from side to side, and these are secured by a few 
more circular strips. This dressing should only be applied 
tight enough to retain its hold upon the parts. In three or 
four days it is generally so loose as to require to be replaced 
by another. It is now many years since we abandoned strap- 
ping the testicle, because its employment not infrequently 
produces the symptoms of shock, i. e., reflex paralysis of the 
vascular nerves, especially the splanchnic, through sudden and 
violent disturbance of the parts, and even gangrene of the 
scrotum in some cases followed. 

In cases of circumscribed acute hydrocele excellent results 
were often obtained from punctures with a sharp-pointed bis- 
toury. Abscesses of the epididymis should be treated in ac- 
cordance with the general rules of surgery. The hypertrophy 
of the connective tissue in the vicinity of the head of the epi- 
didymis obstinately resists all kinds of treatment, both local 
and general ; still, in some cases we have obtained good results 
from the internal administration of the preparations of iodine. 

Chronic Hydrocele. Hernia Aquosa. 

"When the serous effusion which is poured out in the course 
of an acute inflammation of the testicle, between the two lay- 
ers of the tunica vaginalis propria, is not absorbed after the in- 
flammatory phenomena have subsided, or, worse still, more and 
more effusion continues to form, there results a painless en- 
largement of the scrotum and distention of the tunica vaginalis 
propria, which has been called chronic hydrocele, or hernia 



GONORRHCEA, VENEREAL CATARRH. 59 

aquosa, in contradistinction to acute hydrocele. The tumor 
may attain the size of a goose-egg, a man's fist, or even a 
child's head, according to the quantity of the fluid that accu- 
mulates in the sac. The testicle is always found located in the 
lower and posterior part of the distended tunica vaginalis. 
The fluid contained in the latter is clear and watery, and gen- 
erally contains a large quantity of salts and albuminoids, prob- 
ably also the so-called fibrogenous substance (Yirchow). As a 
result of injury, such as blows, squeezing, and the like, haemor- 
rhage readily occurs into the tunica vaginalis, whereby the 
serous fluid becomes bloody (hematocele). "When the hydro- 
cele lasts for a long while, excrescences not infrequently form 
upon the parietal or visceral layer of the sac. These become 
converted either into a fatty or cartilaginous substance, soon 
drop off and fall into the hydrocelic fluid (free or floating bodies 
of the tunica vaginalis). Sometimes the tunica vaginalis un- 
dergoes such a hyperplastic thickening that it becomes trans- 
formed into a leathery or cartilaginous callosity. This condi- 
tion is usually associated with the partial union of the two lay- 
ers. Such adhesions may give rise to the formation of bilocu- 
lar or multilocular cavities. We obtain positive proof of the 
presence of fluid in the tunica vaginalis if, on examining the 
scrotum with a light, it is found to be transparent, and fluc- 
tuation is felt in it. In hsematocele the scrotum, when ex- 
amined by the help of a candle-light, is less or not at all trans- 
parent. Before tapping a hydrocele, the absence of a hernia 
must be established beyond all doubt. Permanent pressure 
by the effused fluid may result in atrophy of the testicle and 
of the cremaster muscle. 

In a few rare cases we have succeeded, by simply tapping 
the tunica vaginalis, in curing chronic hydrocele. The best re- 
sults are obtained by injecting iodine into the cavity after the 
tapping, thereby setting up an adhesive inflammation which 
results in a union of both layers of the membrane. Or Lugol's 
solution may be used, the formula of which is as follows : 

^ Iodi. puri, 5*00 [3iv]; 
Kali, iodata, 10*00 [3 viij] ; 
Aqua destil., 100-00 [ § iij, 3 ijss.j. 
Or equal parts of tr. iodine and spirits of wine may be used. 



60 PATHOLOGY AND TREATMENT OF SYPHILIS. 

In those cases in which the tunica vaginalis has probably 
undergone a condition of sclerosis, no injection of iodine should 
be made, because, owing to the lack of vascular supply to the 
tissues, not only is a union of the opposing surfaces not to be 
expected, but sloughing of the testicle may be brought about. 
In such cases we recommend the radical operation for hydro- 
cele under strictly antiseptic conditions. 

[Yarious other remedies have been used, as injections into 
the tunica vaginalis, for the cure of hydrocele. Carbolic acid 
has been employed here with excellent results. The follow- 
ing is the formula for it : 

B Acid carbol. crystal., 10 parts; 
Glycerine, 90 parts. M. 

Of this solution four to six grammes ( 3 j to 3 jss.) are injected 
after the effusion has been drawn off' with a trocar and canula. 
I have succeeded admirably in exciting sufficient inflammatory 
action in the opposing surfaces of the sac by introducing through 
the trocar some crystals of red oxide of mercury on a thin, 
moistened whalebone rod directly after the hydrocele was 
tapped. But a certain percentage of failures will result from 
the use of any preparation, the only reliable method being the 
radical cure proposed by Yolkmann, and modified by Berg- 
mann, of Berlin.] 

Inflammation of Cowper's Glands. 

In very rare cases the inflammatory process extends from 
the bulbous and membranous parts to the excretory ducts of 
Cowper's glands. The disease of the glands can only be as- 
sumed to be present with certainty when the connective tissue 
surrounding them is also involved. In this case there originates, 
between the scrotum and anus, on the right or left side of the 
raphe, a more or less circumscribed swelling, which is pain- 
ful at the slightest touch. Micturition is somewhat difficult. 
Under appropriate treatment the swelling disappears entirely 
in ten or twelve days ; in very rare cases it terminates in sup- 
puration, opening externally or bursting into the urethra. As 
soon as fluctuation can be detected the abscess should be 
opened in order to prevent it from rupturing into the urethra. 



GONORRHOEA, VENEREAL CATARRH. 61 

Morbid Alterations that are produced in the Prostate by Gonor- 
rhoea of the Urethra. 

Contrary to the views that were formerly entertained re- 
garding the structure of the prostate gland, it is now known 
to consist in greater part of muscular substance (sphincter vesicae 
externus) and of a number of tubular glands in addition to 
glandular structure. The excretory ducts of the prostate, like 
the follicles of the fossa navicularis of the urethra, are liable 
to become diseased through the propagation of the gonorrhceal 
discharge to the deeper parts of the urethra. Here, too, we 
distinguish a serous, mucous, and purulent catarrh. As a rule, 
the severity of the catarrhal disease of the prostate corresponds 
to the intensity of the catarrhal affection of the urethra. 

The serous and mucous catarrh of the prostate is generally 
the result of an inveterate gonorrhoea which the patient has 
neglected. It manifests itself by a drop of tenacious, albu- 
minoid matter appearing several times daily, unattended with 
pain, at the meatus, producing a dirty-grayish spot upon the 
linen, and rendering the spots stiff as if starched. These spon^ 
taneous discharges are most probably due to the occasional con- 
tractions of the muscular tissue of the prostate ; but the press- 
ure caused by the passage of faeces during the act of defecation 
doubtless also propels the discharge forward. Owing to the 
capillary engorgement which takes place in the prostatic por- 
tion of the urethra, the patient is troubled with dribbling of 
urine at the end of each act of micturition. The serous and 
mucous prostatic catarrh may remain in this condition for 
many years. Should the patient indulge in excesses in Baccho 
et Venere, dysuria, tenesmus, and ischuria will soon become 
associated with this harmless complaint. If the catarrh per- 
sists for a long time, the excretory ducts of the prostate will 
become dilated, and in time the discharge becomes inspissated, 
and concretions form in the crypts of the gland. Gradually 
the mucous membrane of the neck of the bladder also becomes 
attacked by catarrh, and, as a result, we then have frequently 
recurring spasmodic contractions of the neck of the bladder. 
The persistence of this muscular activity leads to hypertrophic 
development of the muscular element of the prostate. Chronic 



62 PATHOLOGY AND TREATMENT OF SYPHILIS. 

prostatic catarrh, however, is manifested not only by difficulty 
in urinating, bnt also by febrile paroxysms, especially when it 
is complicated with stricture of the urethra. 

Purulent prostatic catarrh originates from the propagation 
of the acute purulent urethral gonorrhoea to the prostate, or 
also from injuries of the gland (the introduction of catheters, 
bougies, impaction of calculi). As a result of one or another 
kind of irritating causes, a serous transudation of the submucous 
tissue of the prostate and an exaggerated amount of secretion 
in the glandular part of the organ (serous glandular catarrh) are 
produced. During the time that these lesions are developing in 
the prostate the secretion of purulent matter in the urethra dies 
out, and the only discharge that then appears at the meatus is 
that from the prostate gland — a sticky and tenacious fluid. 
Gradually small collections of pus form in the gland, corre- 
sponding to the number of the excretory ducts affected. Pri- 
mary diffuse suppuration of the prostate occurs only in those 
cases which are traumatic in their origin. So long as the oede- 
matous swelling of the prostate is not very intense, the pus- 
corpuscles originating in the crypts become mixed with the 
normal secretion of the gland and form with it a gluey, yel- 
lcfwish-green fluid. In progressive suppuration the cavities of 
the gland gradually become filled with pus and dilated, next 
some of the glandular spaces coalesce and the entire prostate 
is then permeated by large cavities. These small abscesses 
break on the tenth day after the onset of the prostatitis, and, 
as a rule, rupture into the urethra. The pus tunnels its way 
into the rectum only in those cases in which suppurative inflam- 
mations have occurred repeatedly, and especially when insti- 
gated by traumatic causes. The muscular part of the pros- 
tate suffers no pathological alteration ; it is only in a constant 
state of contraction, thereby expelling the secretion, and causes 
tenesmus of the neck of the bladder and the anus. 

Patients suffering from prostatitis are troubled on the one 
hand with difficulty in defecation, and, on the other, from fre- 
quent desire to urinate. For the purpose of expelling the 
urine forcibly, the patients, taking a deep inspiration, endeavor 
to compress the bladder by the action of the diaphragm and 
the pressure of the abdominal walls. Through the action of 



GONORRHCEA, VENEREAL CATARRH. 63 

the levator-ani muscle, however, the prostate is elevated and 
compressed against the symphysis pubis, thus causing still more 
compression of the urethra that is already narrowed, and en- 
tirely preventing the flow of the urine. Not till the patient, 
completely exhausted, becomes totally passive, and entirely 
avoids straining, will the urine flow in drops or in a very thin 
stream variously shaped, causing a violent burning sensation 
in the urethra. Like patients suffering from stone, those suf- 
fering from prostatic disease seek, by pulling or manipulat- 
ing the penis, to ease the flow of the urine. The introduc- 
tion of a catheter or sound is quite difficult, and such in- 
struments only will pass as have a large curve. Just at the 
moment when it is necessary to depress the handle of the sound 
for the purpose of passing it into the bladder, the beak is often 
turned to one side or the other, because the urethra, in conse- 
quence of the unequal enlargement of the prostate, has devi- 
ated from its normal position, and the instrument is twisted 
to the right or left, according as the right or left lobe is more 
swollen. When the central part of the prostate is swollen it 
is entirely impossible to introduce an instrument into the blad- 
der, or this can only be done by force. By a digital examina- 
tion per rectum, the anterior wall of the gut is found to be 
bulged out by a painful tumor. This painful condition of 
prostatitis generally lasts from five to eight days. Prostatitis 
terminates either in gradual absorption of the swelling or in 
suppuration. The latter is generally ushered in by febrile 
movement, indeed even a chill may occur. The moment the 
pus is evacuated the patient feels relieved. We have never 
seen infiltration of urine and fistulse following prostatitis. 
When the abscess bursts into the rectum, fecal masses may find 
their way into the cavity of the abscess, causing grave compli- 
cations, such as gangrene and pysemia. If the abscess opens 
into the rectum or urethra, the disease will almost always ter- 
minate unfavorably. 

Serous and mucous catarrh of the prostate may be mistaken 
for a condition of this organ that has been called jprostator- 
rhoea. In consequence of sexual excitement, unaccompanied 
by ejaculation, the prostate may pour out its secretion ; the 
patient becomes aware of this by finding a drop of sticky albu- 



64: PATHOLOGY AND TREATMENT OF SYPHILIS. 

minous fluid upon his linen, and by the moisture of the lips of 
the meatus. At the same time he suffers from pain in the 
perineal part of the urethra during micturition. 

Strictly speaking, prostatorrhoea is no pathological con- 
dition, and of little consequence to the general system. Char- 
latans, however, make very extensive use of it, designating it 
as spermatorrhoea for dishonest purposes. 

In very rare cases extensive infiltration occurs in one of the 
ischio-rectal spaces, as a result of urethral gonorrhoea. This 
hinders the patient from walking, standing, defecating ; indeed, 
even lying on the affected side is irksome, but micturition and 
the introduction of a catheter are not prevented. On intro- 
ducing the index-finger into the rectum, the physician discov- 
ers on one side, but never at the anterior wall of the rectum, a 
very sensitive swelling, which subsequently may become ab- 
sorbed. In most cases, however, it undergoes suppuration, and 
the pus is evacuated into the rectum, a condition liable to re- 
sult in rectal fistula. To prevent this perforation of the rec- 
tum, an early incision should be made through the skin over 
the affected ischio-rectal space. 

In the vast majority of cases of inflammation and swelling 
of the prostate, resolution takes place. The more intense the 
pains are in the perinseum, and the greater the swelling of the 
gland, the greater is the probability that it will suppurate. In 
consequence of the suppuration, a large part of the gland is 
not infrequently destroyed. In scrofulous and tuberculous 
persons an unfavorable termination of the prostatitis may be 
anticipated. Opening of the prostatic abscess upon the peri- 
nseum seems to occur only in those cases in which the tissues 
surrounding the gland are affected more than its stroma. The 
irritative condition of the prostate may, in some cases, extend 
to one of the seminal vesicles or testicles, and thereby produce 
spermatorrhcea, or inflammation of these organs. Chronic 
prostatitis — i. e., serous or mucous prostatic catarrh — is at- 
tended by little danger, but in the aged may occasion prostatic 
hypertrophy. 

The first duty of the physician is to relieve the difficulty 
in micturition and the violent pains that radiate toward the 
perinseum, anus, and penis. This is effected by the application 



GONORRECEA, VENEREAL CATARRH. 65 

of warm cataplasms, tepid sitz-baths, and narcotics adminis- 
tered internally and locally. Accordingly, we order twenty 
drops of tincture of cannabis indica every three hours, on a 
lump of sugar, or belladonna suppositories, if the rectum tol- 
erates them. If the pain is confined to one spot in the peri- 
naeum, and the dysuria is not very severe, cold compresses 
may be applied, and the following ointment rubbed in upon 
the perinaeum : 

^ Extract, bellad., l'OO [grs. xvj] ; 

Ung. neapol. [ung. hydrarg.], 10*00 [ 3 ij, 3 jj]. 
M. Ft. ung. 

The rectum should be evacuated daily, either by the ad- 
ministration of castor-oil or by means of enemas of olive or 
castor oil. In order to keep open the canal for the passage of 
the urine, a Nekton catheter should be inserted and retained 
in the urethra until the swelling subsides or the abscess 
bursts. For the purpose of allaying the thirst, we recom- 
mend weak lemonade or sweetened water acidulated with acid. 
Halleri [aromatic sulphuric acid]. The diet should consist of 
broths, milk, stewed fruit, ice-cream, and the like. Abscesses 
and fistulse are to be treated in accordance with the rules of 
general surgery. For the hypertrophy of the gland that re- 
mains, the physician is unable to devise any remedy. In 
chronic catarrhal prostatitis, benefit may be derived from the 
internal administration of tinct. ferri chloridi, and the mineral 
waters, such as Franzensbad, Giesshubel, Rohitsch, Preblau, 
Kissingen, Selters, Luhatschowitz, and others. Should an ob- 
stinate mucous discharge from the urethra remain after the 
inflammatory phenomena have disappeared, we advise the pa- 
tient to take the following pills : 

5 Iodureti ferri, l'OO [grs. xvj] : 
Spirit, terebinth., 0*50 [grs. viij] ; 
Ext. gentiana, q. s. ft. bolus, fermentur tales No. 10. 
S. One pill to be taken three times a day. 

[In acute prostatitis, as in affections of the organs in this 
vicinity generally, I have often succeeded in aborting the dis- 
ease by the application of five or six leeches to the perinseum, 
or at the margins of the anus, and, when the disease has become 
5 



66 PATHOLOGY AND TREATMENT OF SYPHILIS. 

chronic, one or more blisters over the perinaeum will almost 
always have a happy effect.] 

Inflammation of the Seminal Vesicles in consequence of Urethral 

Gonorrhoea. 

The colliculus seminalis may be described as the starting- 
point from which the inflammatory disease of the urethra and 
of the neck of the bladder attacks the organs that secrete 
and conduct the semen. It is even more difficult to de- 
scribe fully the pathological condition of the inflammatory 
process in the seminal vesicle than that of the prostate. We 
can only draw certain inferences from appearances found in 
the cadaver as to the nature of the disease. The experi- 
enced physician will be able, on examination with the finger 
in the rectum, to detect, in pronounced cases, inflammation 
of the seminal vesicle. The latter is situated on the posterior 
surface of the bladder, directly behind the prostate, and, when 
inflamed, will assume the form of an oblong oval, painful and 
hot swelling, having a doughy feel. The subjective sensations 
in inflammation of the seminal vesicle differ but little from 
those in prostatitis. There is but one symptom that belongs 
exclusively to the disease under consideration, namely, the 
erections are well-nigh constant, and so painful as to consti- 
tute priapism. According to the observations of Lallemand, 
Gosselin, and Pitha, involuntary seminal emissions occur, at- 
tended by burning pains, the semen occasionally being red 
from an admixture of blood (red pollutions), or yellow from 
pus. In the intervals between the involuntary emissions, dis- 
charges from the urethra containing spermatozoa mixed with 
blood or pus also take place. A continued fever becomes su- 
peradded very early to this local phenomenon. In cases of 
intense inflammation the seminal vesicle may become trans- 
formed into a veritable pus-receptacle, which gradually empties 
itself into the urethra, or ruptures posteriorly into the rectum. 
As a result of suppuration, the seminal vesicle may disappear \ 
entirely or become obliterated. If the disease assumes a chronic 
character, the seminal vesicle may undergo induration, calcifi- 
cation, and ossification. In tuberculous persons the exudation 
in and around the vesicle may undergo caseous degeneration. 



GONORRHCEA, VENEREAL CATARRH. 67 

The result of grave disease of both seminal vesicles is sexual 
impotence. There are no special remedies that can be resorted 
to in the treatment of inflammation of these organs, and those 
that have been found efficacious in the treatment of prostatitis 
will, in general, also answer here. 

Functional Disease of the Seminal Vesicle and of the Testicle. — 
Spermatorrhoea, Seminal Emissions, Pollutio Diurna. 

The opinion prevails, not only among laymen but also among 
medical men, that spermatorrhoea is of very frequent occurrence ; 
but, according to our observation, it is quite the reverse. The 
disease occurs less frequently in consequence of the extension 
of gonorrhoea than from sexual excesses, onanism, etc. In 
most of the cases, the morbid condition which is looked upon 
as spermatorrhoea is really due to a constant discharge from 
the prostate (prostatorrhoea). 

Through excessive indulgence and unnatural gratification 
of sexual intercourse the secretory and excretory seminal or- 
gans are kept in a constant state of irritation, gradually pro- 
ducing exhaustion, atrophy and paralysis of the muscular ap- 
paratus appertaining to them. The beginning of the disease 
manifests itself by a rapid discharge of semen whenever the 
least excitement of the genital organs occurs, the erections, 
however, being short in duration and incomplete. Gradually 
the ejaculation of semen takes place even without any erotic 
thoughts or voluptuous sensations. "While at first the emissions 
only occur at night, perhaps several times in one night (polluti- 
ones nocturnse), later on they take place even in the waking 
hours, with the penis perfectly relaxed, without any erotic 
thoughts — sometimes, indeed, attended by unpleasant feelings. 
The least psychical excitement, the most insignificant disturb- 
ance of the genital organs, indeed the ordinary act of mictu- 
rition and defecation, are sufficient at times to produce an 
ejaculation of semen. Under these circumstances this fluid 
gradually loses its consistency, becomes watery, and resembles 
an albuminous secretion mixed with viscid mucus ; the sper- 
matozoa constantly diminish in numbers. Finally, it is not 
ejaculated, but oozes out from the urethra. This constant 
loss of seminal fluid produces a remarkable mental and physi- 



68 PATHOLOGY AND TREATMENT OF SYPHILIS. 

cal exhaustion of the patient. In some cases, marked psy- 
chical disturbances, spinal diseases, and paralysis, may grad- 
ually supervene. The urine of these patients is generally tur- 
bid, and cloudy, and has the odor of freshly-ground bone, due 
to its being mixed with semen. Notwithstanding the great 
loss of the seminal fluid, some of the patients are said to be 
capable of procreation ; in most cases, however, prolonged 
spermatorrhoea produces impotence. 

The treatment of spermatorrhoea is not satisfactory. The 
efforts of the physician are limited to measures that will pre- 
vent all mental and psychical influences which directly or indi- 
rectly irritate the genital organs, and which will brace up the 
drooping spirits of the patient. For the purpose of prevent- 
ing the seminal emissions the patient should keep cool, live 
upon a nutritious but unstimulating diet, moderately indulge 
in light wines, take cool baths and frictions, cold douches to the 
perinseum, and clysters of cold water, methodical use of the 
cold-water cure, or sea-baths. Hypochondriac patients should 
be urged to take exercise, try country air, so as to become in- 
vigorated in every possible way. "We administer internally, 
against the frequent emissions : 

]$ Lupulini puri, 0-50 [grs. viij] ; 
Camphora, 0*10 [gr. jss.] ; 
Sacchar. alba., 2*00 [grs. xxxii]. 
M. Ft. pil. No. X. S. Two pills to be taken during the day, and 
one directly before going to bed. 

Or we prescribe : 

1$ Carb. f erri sacchar., 2*00 [grs, xxxij] ; 
Camphora, 0-20 [grs iij] ; 
Pulv. secale cor. ; 
Sacchar. alba., aa 5'00 [Biv]. 
M. Div. in dos. aequalis No. XV. S. Three or four powders to be 
taken daily. 

If the erections are incomplete, or premature ejaculation of 
the semen takes place, iron and quinine will be found bene- 
ficial, and may be prescribed in the following manner : 

3 Tr. ferri acet. aether., 2*00 [grs. xxxij] ; 
Tr. cort. chinas vinos, 50'00 [^ jss., 3iv]. 
M. S. One teaspoonful to be taken four times daily in sweetened 
water. 



GONORRECEA, VENEREAL CATARRH. 69 

We also use the following : 

3 Extr. quassias, 20*00 [ f ss., 3iv] ; 
Sulph. ferri puri, 2*00 [grs. xxxij] ; 
Pulv. cort. cinnamom., 2-00 [grs. xxxij]. 
M. Ft. pil. No. CXX. S. Ten pills to be taken daily two or three 
times. 

In those cases in which the erections and ejaculations do 
not take place at all, jet the semen flows constantly, we use : 

IJ Acid, phosph. dil. ; 

Sulph. quinine, aa 2 - 00 [grs. xxxij] ; 
Camphora, 0-50 [grs. viij J ; 

Ext. cascarillad, q. s. ut fiant pil. pond., 0'15 [grs. ijss.]. 
S. Four or five pills to be taken three times daily. 

Bromide of potassium may also be prescribed in these cases. 
We generally order half of the following mixture, to be taken 
morning and evening : 

$ Kali bromat., 5'00 [3iv] ; 

Aqua destil., 100-00 [ § iij, 3 ijss.] ; 
Syr. cort. aurant., 12-00 [3 iij]. M. 

Locally, we advise the use of the following measures : 
Wax bougies (sonde a demeure) to be introduced and kept in 
the urethra, injections of tanno-glycerine into the urethra 
(0*50 [grs. viij] of tannic acid and 200*00 [ 3 vj, 3v, 3j] of 
glycerine), the injection of a weak solution of oil of cam- 
phor (1£ to 2 grammes [grs. xxiij to xxxij] of camphor to 25 
grammes [3 vj, 3ij] of olive-oil) into the deeper parts of the 
urethra through a soft catheter, faradization of the genital or- 
gans, and the introduction of a cool steel sound. Little or no 
benefit is derived from cauterizing the deeper parts of the 
urethra with nitrate of silver, as recommended by Lallemand, 
while the danger attending this procedure is considerable. 

Diseases of the Bladder caused by Urethral Gonorrhoea. 

The bladder, as a rule, only becomes affected, as a result of 
gonorrhoea, in those cases in which the disease has already in- 
volved the prostatic part of the urethra. At the beginning 
the disease generally attacks the neck of the bladder only ; 
gradually, however, the fundus is also affected. The disease 



70 PATHOLOGY AND TREATMENT OF SYPHILIS. 

of the neck of the bladder has an acute character, while that 
of the fundus is chronic. Hence we distinguish an acute and 
a chronic catarrh of the bladder. 

Acute catarrh of the bladder manifests itself by evidences of 
intense hyperemia and a moderate amount of secretion of mucus, 
the chronic form by a profuse discharge of catarrhal secretion. 
So long as the catarrhal disease is limited to the neck of the 
bladder, the patients complain of frequent desire to urinate 
and to defecate. If the patient endeavors to relieve himself, 
he only succeeds, under the most distressing pains, in passing 
a few drops of concentrated acid or neutral urine. After the 
last of the urine has been voided, one or more drops of blood 
as a rule follow. The urine is generally clear ; on cooling, 
however, a sediment forms, which contains desquamated epi- 
thelium-cells, mucus, sometimes also blood and pus-corpus- 
cles. The discharge from the urethral mucous membrane is 
then reduced to a minimum. A digital examination per rec- 
tum, in most cases, causes an unbearable pain in the region of 
the prostate, and the introduction of a catheter is usually im- 
possible, because the neck of the bladder, in consequence of 
the spasmodic contraction, is impassable. Although febrile 
phenomena are present in all cases of disease of the neck of the 
bladder, nevertheless, not all of the patients are compelled to 
remain in bed ; but if the tenesmus increases to a condition of 
ischuria, violent febrile symptoms, preceded by a severe chill, 
will ensue. If not relieved promptly, the ischuria may cause 
rupture of the bladder and uraemia. 

When properly managed, the acute phenomena will be re- 
lieved in from eight to twelve days. The inflammatory affec- 
tion of the neck of the bladder, however, not infrequently 
extends to the excretory ducts of the prostate and vasa defer- 
entia. A permanent hyperemia of the colliculus seminalis 
remains, and as a result the patient, at each ejaculation, feels 
as if a hot needle were thrust through his perinseum. Acute 
cystitis may relapse from the slightest cause, in which case a 
permanent hypertrophy of the apex of the trigonum Lieu- 
todii (la luette vesicate of Amussai) not infrequently develops, 
causing difficulties in voiding the urine and ejaculating the 
semen. 



GONORRHCEA, VENEREAL CATARRH. 71 

The extension of the inflammatory disease of the urethra 
to the neck of the bladder is promoted or occasioned by vari- 
ous influences. Chief among these are a liberal indulgence 
in fresh, unfermented beer, unfermented wine, champagne, 
and soda-water. In addition, injections unskillfully and vio- 
lently, or too often made, or of too strong solutions, may lead 
to the development of acute catarrh of the neck of the blad- 
der. It is very often occasioned by the violent use of sounds 
and catheters, and by the impaction of calculi. Lastly, an 
acute vesical catarrh, may also be produced by the use of can- 
tharides. 

If acute vesical catarrh is not carefully treated, still more, 
if the injurious influences continue, such as the urethral injec- 
tions, the introduction of catheters or sounds, or the internal 
use of balsamic remedies, a chronic vesical catarrh, or gonor- 
rhoea of the bladder, will be produced. In old persons, who, 
as is well known, not infrequently suffer from prostatic hy- 
pertrophy, and in spinal paralysis, a chronic vesical catarrh will 
readily be produced under the pernicious influences that have 
been mentioned. In chronic catarrh of the bladder, febrile 
phenomena and pain appeal* only at times. The latter consists 
not only of annoying calls to urinate often, but pains also dart 
toward the meatus. The urine is cloudy and opaque, because 
it contains a notable quantity of pus and mucous corpuscles, 
blood-coagula, epithelial cells, and a large amount of salts, 
phosphates, urates, etc. It emits an ammoniacal odor, and re- 
acts alkaline. The alkaline condition is occasioned by the mu- 
cus from the bladder, which acts as a ferment, and as a con- 
sequence carbonate of ammonia develops from the urine while 
still in that viscus, and this salt in its turn causes additional 
irritation. Under unfavorable conditions the catarrhal secre- 
tion in the bladder may attain such a degree that large lumps 
of mucus, pus, and blood are discharged every time urine is 
voided. The sediment becomes tenacious and ropy, an alter- 
ation produced by the action of the carbonate of ammonia of 
the urine upon the mucus and pus. 

Chronic vesical catarrh gives rise to more important patho- 
logical alterations than the acute variety. It results in hyper- 
trophy of the muscular coat of the bladder (la vessie a colonne), 



72 PATHOLOGY AND TREATMENT OF SYPHILIS. 

with simultaneous thickening of the mucous membrane, and 
in consequence of these lesions paralysis of the viscus may 
follow. Gradually the ureters, the pelves, and even the kid- 
neys may become diseased. The mucus, pus, and blood-coagula 
that remain in the bladder may serve as the starting-point for 
the formation of calculi. Finally, suppuration and ulceration 
of the bladder may take place, and hence it is readily under- 
stood how chronic catarrh may terminate in death, either di- 
rectly or by retention of urine, and uraemia. 

Disease of the bladder is the most serious complication 
of urethral gonorrhoea. It has a tendency to relapse and 
to become permanent. So long as the vesical affection is 
limited to the mucous membrane of the neck the prognosis 
is still favorable, but if the disease has extended to the fun- 
dus of the bladder the physician should be guarded in his 
prognosis. 

When the neck of the bladder only is affected, the main 
duty of the physician will be to relieve the vesical spasm and 
the painful micturition. This is best achieved by the removal 
of all causes, discontinuance of the injections, and of the in- 
ternal administration of the balsamic remedies that had been 
employed in the treatment of the gonorrhoea. For the purpose 
of allaying the vesical tenesmus, there is nothing better than 
the local and internal employment of the anti-spasmodic and 
narcotic remedies. Care should be taken, however, in the use 
of the latter to prevent constipation. We have used for a 
long time, with great benefit to the patient, equal parts of in- 
fusion of herba Herniarise and chenopodium ambrosioides, of 
which two or three cupfuls, sweetened with milk and sugar, 
should be taken daily. This infusion has the additional advan- 
tage of diluting the concentrated urine in the bladder without 
causing diuresis. 

In case this remedy affords no relief to the vesical tenesmus, 
the following preparations may be used : 

]J Extr. sem. hyosciami ; 

Extr. cannabis indica, aa 0*50 [grs. viij]; 

Sacchar. alba, 3*00 [grs. xlviij]. 
M. Div. in pulv. No. XX. 
S. One powder to be taken every three hours. 



GONORRHCEA, VENEREAL CATARRH, 73 

B Camphora; 

Ext. cannabis indica, aa 0*50 [grs. viij] ; 

Sacchar. alba, 3*00 [grs. xlvij]. 
M. Div. in dos. seq. No. X. 
S. One powder to be taken every two or three hours. 

If these narcotics also fail to give relief, suppositories of 
belladonna, containing 0*01 [gr. -J-] of the extract,* should be 
resorted to. In patients who do not suffer from constipation, 
suppositories containing morphia, in quantities similar to that 
of the belladonna, or hypodermic injection of morphine in the 
peringeum, may be employed. In the majority of cases warm 
sitz and ordinary baths, and the application of flannels dijyped 
in hot water, wrung out, and applied over the bladder, afford 
considerable relief. The diet of the patient should consist 
only of soup and milk. Sweetened water, to which a few 
drops of acid Halleri [aromatic sulphuric acid], or diluted milk 
of almonds, is the best drink for him. Formerly, it was cus- 
tomary to use, in acute catarrh of the bladder, oleaginous mixt- 
ures and decoctions of linseed with syrupus Diacodii ; in our 
opinion, however, the decoction contains but a slight amount 
of linseed-oil, and of this very little is excreted with the urine 
and finds its way into the bladder. 

If retention of urine has occurred, the bladder should be 
evacuated by the aid of a soft catheter. In cases in which the 
effusion of blood from the capillaries of the neck of the blad- 
der continues, tr. ferri chlorid., administered internally, will 
be found beneficial. [Nothing serves the purpose so well here 
as blistering the perineum. When all other remedies have 
failed, one or two blisters applied upon the peringeum not 
only arrested the bleeding, but gave prompt relief to the vesi- 
cal tenesmus.] 

In chronic vesical catarrh the physician will be called upon 
to evacuate the urine and the ropy secretion several times 
daily, and to diminish the secretion of mucus as much as pos- 
sible. With this object in view, the patient should be allowed 
to drink water plentifully ; also mineral waters containing iron, 
such as Marienbad, Franzensbad, Giesshubler, Ottoquelle, Ro- 

* [I have found this quantity entirely insufficient — half a grain at least being 
necessary.] 



74 PATHOLOGY AND TREATMENT OF SYPHILIS. 

hitscher, Luhatschowitzer, Wildungen, etc. In addition astrin- 
gents, such, as alum, tannic acid, or decoct, f oliorum uvse ursi, 
should be used, as in the following formulae, for the purpose of 
arresting the secretion of mucus by the mucous membrane of 
the bladder : 

5 Fol. uvsb ursi, 20*00 [ § ss., ^ iv] ; 

Ooque c. q. s. aq. comm. per \ h. sub. finem coct. ; 

Adde: Flav. cort. aur., 10-00 [3 viij]; 
Stet in infuso fervids per i hor. vase clauso. 
Colat, 300-00 [ | ix, 3 vj]. 
Adde: Syr. althae, 30*00 [§j]. 
M. S. Half a teacupful to be taken every three hours. 

3 Glycerini puri, 20-00 [ § ss., 3 iv] ; 
Tannini puri, 0*50 [grs. viij] ; 
Aq. destil., 50'00 [§jss., 3 iv]; 
Syr. ononidis spin., 15*00 [ § ss]. 
M. S. To be taken in twenty-four hours. 

We are unable to say anything in favor of the use of lime- 
water or tar- water, or of a solution of corrosive sublimate, 
in this complaint. 

If the muco-purulent secretion of the vesical mucous mem- 
brane does not diminish from the use of the mineral waters 
and astringent remedies, it will be necessary to remove mechani- 
cally the secretion and urinary sediment that stagnate in the 
bladder. For this purpose, we cordially recommend the pro- 
cedure suggested and published by Drs. Erunner and H. von 
Zeissl, of filling the bladder with liquids by hydrostatic press- 
ure without the aid of a catheter. If the bladder does not 
evacuate its contents spontaneously, a catheter having a large 
eye should be introduced, and the organ should be carefully 
washed out with some weak antiseptic preparation, such as a 
solution of carbolic acid or the like. For the purpose of coun- 
teracting the alkaline condition of the urine, we give internally 
potas. chlor., 0*50 [grs. viij], per diem, in solution, with very 
good result. 

Diseases of the Kidney that are produced by Urethral Gonorrhoea. 

]STo morbid conditions that originate in consequence of 
gonorrhoea of the urethra escape the notice of the physician 



GONORRHCEA, VENEREAL CATARRH. 75 

so often as those that develop in the kidneys. The genesis of 
these kidney lesions was but imperfectly known to within a 
comparatively recent period. Many physicians ascribed the 
diseases of the kidney that complicated gonorrhoea exclusively 
to the' large doses of the resinous diuretics which the patients 
took. On the other hand, Chomel and Raver maintain that 
neither the resinous remedies nor the diuretica acria exert any 
unfavorable effect upon the kidneys. Still, we have proof 
that even small doses cause, occasionally, haemorrhage and 
ecchymoses of the neck of the bladder. From this point the 
hypersemia may extend along the mucous membrane of the 
ureters and pelves of the kidneys to the papillae and the 
straight renal tubules, and produce within the latter catarrhal 
proliferation of the cells. Now, it is easy to perceive how 
a catarrh of the bladder, merely by extension, may occasion 
disease in the kidney, since irritation of the neck of the blad- 
der not infrequently occurs even in gonorrhoeal urethritis 
treated without any balsamic remedies. Further, because 
this coexisting catarrhal affection of the straight tubules of 
the kidneys, occasioned perhaps idiopathically, is accompa- 
nied by albuminuria, the resinous remedies were charged with 
having caused the nephritis. It is all the more easy to make 
this mistake, because it is possible, even in healthy kidneys, 
after the use of copaiba, cubebs, etc., in large doses, to pro- 
duce for several days an opacity of fresh urine by the addi- 
tion of strong mineral acids, which is remarkably like that 
caused by the presence of albumen. This opaque sediment, 
however, is not albumen, but the resinous substance precipitated 
by the acid. But, even if the opaque sediment proves to be 
albumen, the lesion can only be regarded as a catarrhal ne- 
phritis desquamativa, and not diffuse nephritis. Now, it is a 
settled fact that the kidneys, in most cases, are not attacked 
by acute gonorrhoea, even if the latter extends to the pros- 
tate and bladder, and that it only produces a catarrh of the 
straight renal tubules when it has existed for a long time and 
involved the bladder. We have only been able to demonstrate 
in the cadaver the presence of suppuration in one or both kid- 
neys in those cases in which bad strictures had already formed 
as a result of gonorrhoea, followed by hypertrophy or ulcera- 



76 PATHOLOGY AND TREATMENT OF SYPHILIS. 

tions of tlie prostate, with or without purulent catarrh of the 
bladder. Inflammation of the jpelves of the kidneys, in conse- 
quence of gonorrhoea, occurs more often than is supposed. 
The diagnosis of this condition is based upon the presence of 
febrile movement analogous to intermittent fever, of an amount 
of albumen in the urine correspondingly greater than the pus 
in it, the microscopical demonstration of pus-corpuscles, and 
irregular pavement epithelium of the renal pelvis. The urine 
in pyelitis has an acid reaction, being directly the reverse of 
the condition that appertains to catarrh of the bladder that has 
existed for a long time. The patients complain mostly of a 
dull pain in the region of the kidney, and the organ itself is 
sensitive on pressure. 

In most cases the patient complains — if not at first, at any 
rate later in the course of the catarrhal nephritis — of a dull, 
sometimes of a violent pain in one or both lumbar regions, 
which becomes aggravated at the slightest touch, and usually 
extends downward along the course of the ureters. Not in- 
frequently the disease manifests itself by more or less severe 
febrile movement. The urine in such cases is markedly di- 
minished at first ; later, in most instances, it is increased, and 
is generally of a pale-yellow color. As a rule, it contains a 
moderate amount of albumen ; but, notwithstanding the pres- 
ence of albumen, the specific gravity is lower than normal. 
After standing for some time the urine deposits a sediment, 
in which the epithelial cells of the ureters and bladder, along 
with mucus and pus-corpuscles, hyaline casts, cylindrical epi- 
thelium, and occasionally fibrine casts are found. The urine 
reacts slightly acid, but, if the disease persists for a long time, 
it will become alkaline, owing to the decomposition of the salts 
of the urine in the bladder. We then find the well-known cof- 
fin-lid-like crystals of the triple phosphates ; sometimes blood- 
corpuscles are also present. The condition of the extravasated 
blood will serve to show whether the blood that is mixed with 
the urine originates in the bladder or in the kidneys. Blood 
coming from the ureters generally forms clots, shaped like casts 
of these tubes. In haemorrhage from the bladder the blood 
is not intimately mixed with the urine, and the urine that is 
voided at first is only slightly red in color, but that voided later 



GONORRHCEA, VENEREAL CATARRH. 77 

becomes as intensely red as if it were pure blood. In hemor- 
rhage from the kidney the blood is thoroughly mixed with the 
urine, and the latter has a uniform color from the beginning to 
the end of micturition. For the purpose of ascertaining defi- 
nitely the presence of blood-corpuscles in the urine in slight 
renal haemorrhages, the urine should be subjected to the potash 
test, which consists in boiling some of it in a test-tube, adding 
a few drops of a solution of caustic potash, and then boiling 
it again. The solution precipitates the phosphates, carrying 
the coloring-matter of the blood with them, and the sediment 
is thereby colored red. 

The course of a renal catarrh occasioned by gonorrhoea is 
usually rapid and favorable. The prognosis depends upon the 
intensity of the primary disease. If the vesical catarrh is in- 
tense and purulent, there is danger that the catarrhal nephritis 
will become suppurative. 

Renal catarrh, due to gonorrhoea of the bladder, generally 
disappears when the primary disease disappears. Hence the 
treatment of the vesicle and renal catarrh mast go hand in 
hand. Eegarding the therapeutics of the disease of the blad- 
der, we refer the reader to what has already been said above. 
The patient should avoid everything that is liable to produce 
marked fluxion to the kidney, especially food and drink sea- 
soned with much salt, and also all kinds of diuretics. Cold 
water, weak lemonade, and milk of almonds are best suited for 
drinks, and milk and milk-diet as food. Stimulating the skin 
by means of hot baths is especially useful. The following may 
be employed for the purpose of arresting the secretion of the 
mu co-pus : 

3 Tannini puri, 1*00 [grs. xvj]; 
Camphora, 0'50 [grs. viij] ; 
Sacchar. alba, 5*00 [3iv]. 

M. Div. in dose No. 15. 

S. Four powders to be taken daily. 

I£ Glycerini puri, 20*00 [ § ss., J>iv] ; 
Tannini puri, 1*00 [grs. xvj] ; 
Aqua destil., 100*00 [ § iij, 3 ijss.]. 

S. To be taken during the day. 

In profuse renal haemorrhage we administer tr. ferri mur. 
In very obstinate bleeding and persistent lumbar pain, cold 



78 PATHOLOGY AND TREATMENT OF SYPHILIS. 

compresses should be applied to both renal regions. The 
treatment of the pyelitis consists in the internal administration 
of tannic acid in the manner described above. [In renal 
haemorrhage, and also in pyelitis, I can heartily recommend 
the use of dry cups over the lumbar region as often as may be 
deemed necessary. From twenty to forty cups may be applied 
and repeated. It has rendered me excellent service where 
other much-vaunted remedies failed.] Dittel obtained very 
good results from the inhalation of the ethereal balsamic 
remedies. 

Gonorrhoea of the Female. 

We distinguish (1) gonorrhoea of the vulva, (2) of the va- 
gina, (3) of the uterus, and (4) of the urethra. 

The most frequent form is vaginal gonorrhoea, next is 
vulvar and uterine, and the rarest is the urethral form. Usu- 
ally several parts of the genito-urinary mucous membrane are 
affected at the same time. Yaginal gonorrhoea is very often 
associated with vulvar or uterine, urethral with vulvar or vagi- 
nal, vaginal with urethral and uterine gonorrhoea. The en- 
tire genito-urinary tract is very seldom attacked in toto by gon- 
orrhoeal disease. 

The causes of gonorrhoea in the female are infection, ex- 
cessive sexual intercourse, and mechanical and chemical irrita- 
tion of the mucous membrane. Constitutional diseases, such 
as chlorosis, scrofula, syphilis, and similar blood dyscrasise, ir- 
regularities of menstruation, abortions and difficult confine- 
ments, neoplasms, and surgical operations, may also occasion a 
mucous catarrh or prolong one that has originated in some 
other manner. 

1. Gonorrhoea of the Yulva. 

Two kinds of vulvar catarrh may be said to occur: an 
idiopathic variety and one that has been produced by propa- 
gation from adjacent parts. Idiopathic vulvar catarrh origi- 
nates mostly in consequence of onanism, but may also be caused 
by the gonorrhoeal discharge of men. "Vulvar catarrh originat- 
ing through propagation results from the action of vaginal or 
urethral discharge of women affected with gonorrhoea, or it ac- 



GONORRH(EA, VENEREAL CATARRH. 79 

companies soft chancres and syphilitic affections situated on 
the vulva. 

The pathological lesion consists either of a hyperemia of 
the affected mucous membrane or its consequent effect (serous, 
mucous, or epithelial catarrh), or the follicles are inflamed and 
become filled with pus (vulvitis purulenta). Yulvar catarrh be- 
gins with sensual itching, which changes to a burning sensation. 
If any part of the mucous membrane is denuded of epithe- 
lium, or excoriations and erosions such as usually occur on the 
labia majora and minora at the fourchette are present, the pa- 
tients will suffer severe pain during micturition. If the disease 
becomes aggravated the parts of the vulva, provided with loose 
connective tissue, become swollen. The nymphae become en- 
larged to three and four fold their size, and, as a consequence, 
project in front of the labia majora and are strangulated by 
them. In milder forms of the disease — serous, mucous, or 
epithelial catarrh — the discharge from the vulva is slight, 
mucoid, and tenacious. In purulent vulvitis it is considerable 
in quantity, thick like cream, and yellowish-green in color, 
emits a peculiar, fetid odor, irritates the adjacent mucous 
membrane, and produces erythema of the skin in the genito- 
crural and inguinal folds. Warts and condylomata are some 
of the most frequent effects of vulvar gonorrhoea. 

Mild cases get well soon, if the diseased parts are washed 
several times daily, and the sound parts are protected by com- 
presses of muslin or wadding. If the inflammation of the 
mucous membrane is intense, compresses, dipped in cold water 
and frequently changed, should be ordered, and pledgets of 
lint, dipped in a solution of lead or of zinc, placed between 
the labia majora. 

]$ Ext. Saturni [plumb, acet.], 5 - 00 [3iv]; 
Aqua destil., 200*00 [ § vj, 3 v, 3j]. 
M. S. For external use. 

3 Zinci mur., 2*00 [grs. xxxij] ; 

Aqua destil, 200*00 [ § vj, 3 v, 3j]. 
M. S. For external use. 

Excoriations that exhibit no tendency to cicatrize may be 
touched with the solid nitrate of silver. 



80 PATHOLOGY AND TREATMENT OF SYPHILIS. 

2. Gonorrhoea of the Yage^a. 

We distinguish a serous, mucous, or epithelial, and a puru- 
lent catarrh (kolpitis), according to the severity of the inflam- 
mation. 

Every vaginal gonorrhoea begins by an undefined sensation, 
something between tickling and pain. In the serous and mu- 
cous catarrh, the vagina is only slightly sensitive, especially at 
the beginning of the morbid process. In kolpitis the burning 
sensation is more marked ; the introduction of the finger or of 
a vaginal speculum gives rise to unbearable pain. Micturition 
also causes more or less pain in vaginal gonorrhoea. The dis- 
charge of a mucous gonorrhoea of the vagina is thin, whitish, 
like mucus, or yellowish ; the discharge of the purulent variety 
is thick, like cream, and has a yellowish-green color. The dis- 
charge of both varieties has an acid reaction, in contradistinc- 
tion to the discharge from the inflamed mucous membrane of 
the urethra, and of the cervix uteri, which reacts alkaline. 
This acid reaction seems to be due to the fact that the virginal 
vulvo-vaginal mucous membrane furnishes a smegma-like secre- 
tion containing a fatty acid, while the follicles of the cervical 
portion of the uterus furnish a mucous secretion. Examined 
with the aid of a microscope, the discharge of a vaginal gonor- 
rhoea is found to contain mucous corpuscles, a few pus-corpus- 
cles, cast-off epithelium cells, and now and then a few blood- 
globules. 

In attempting to make a digital examination during the 
initial stage of the disease, the vaginal orifice is found to be 
contracted and the temperature of the canal increased. Its 
mucous membrane is felt to be either soft and smooth, or 
rough and dry. On examining with a speculum a vagina that 
is affected with gonorrhoea, the mucous membrane, after the 
discharge that has accumulated at the mouth of the speculum 
has been wiped away with some cotton on a whalebone rod, is 
found to be swollen, dotted with red spots, here and there ex- 
coriated, and turgid with blood. Occasionally the anterior 
part of the vagina especially is studded with minute granula- 
tions, which have originated through swelling of the follicles 
and of the papillae of the mucous membrane. In pregnant 



GONORRHCEA, VENEREAL CATARRH. 81 

women these granulations attain an enormous size (vaginitis or 
elytritis papulosa). As it is not possible to use the speculum in 
young girls, we succeeded very well, in some cases, in lighting 
up and examining the vagina by the aid of Griinfeld's ure- 
thral endoscope. 

Gonorrhoeal disease of the vagina generally begins at the 
lower third of the canal and gradually extends to the fornix, 
indeed, sometimes to the cervical canal of the uterus. The 
general condition is but slightly affected by a mucous gonor- 
rhoea. The purulent form, on the contrary, is attended, espe- 
cially at the beginning, by fever, lassitude, loss of appetite, 
back-ache, vicarious menstruation, and other functional disturb- 
ances, on account of which the patients acquire a chloro-ansemic 
appearance. The local disturbances consist of erythematous 
redness of the external surfaces of the genital organs, caused 
by the discharge from the vagina flowing over them. The 
duration of a vaginal gonorrhoea depends upon the habits of 
the patient, certain constitutional conditions, and the manner 
of treatment. A purulent gonorrhoea, in women who are 
otherwise healthy, can be cured in about fourteen days, pro- 
vided menstruation does not interrupt the treatment and the 
cure, which it is apt to do, experience having shown that it 
will start the disease anew, after it was entirely checked. 
If the treatment of an acute vaginal gonorrhoea is abandoned 
too early, and the woman indulges in sexual intercourse, the 
inflammation either relapses or the catarrhal hypersecretion 
becomes permanent {chronic vaginal gonorrhoea). However, 
even a vaginal gonorrhoea which, at its incejMdon, was of the 
catarrhal mucous form, may, through unfavorable circum- 
stances, especially anaemia and frequent and irregular menstrua- 
tion, become protracted and difficult to cure (leucorrhosa). The 
discharge from chronic catarrh is almost colorless, more mucous 
than purulent. As a result of the chronic process, and still 
more from the astringent liquids used against it, the mucous 
membrane becomes hypertrophied, loses its velvety appearance, 
feels rough and dry, like tanned leather (xerosis vagina), and 
causes a grating noise when a speculum is introduced. 

For the purpose of curing a vaginal gonorrhoea, the woman, 
above all things, must practice the utmost cleanliness. In 
6 



82 PATHOLOGY AND TREATMENT OF SYPHILIS. 

cases of intense swelling of the mucous membrane, cold com- 
presses, cool sitz-baths, or the cold-water vaginal douche, by 
means of the fountain-syringe, should be employed. After 
the inflammatory swelling has subsided, and the hypersensi- 
tiveness has diminished, mineral astringents, and, if these fail, 
vegetable astringents and tonic fluids, may be injected into the 
vagina. These injections may be much stronger than those used 
in urethral gonorrhoea in men. "We prescribe the following : 

I£ Alum crudi, 10-00 [3viij]; 
Aqua destil., 500-00 [§ xvj]. 
M. S. For external use. 

3 Cortic. quercus or radio, ratanh., 50-00 [§ jss., Bviij] ; 
Coque cum aqua, 1000*00 [ § xxxij] usque ad remnant 
500-00 [ I xvj] cola. 
M. S. For external use. 

3 Zinci sulph., 5-00 [3iv]; 
Aqua destil., 500-00 [ § xvj] ; 
M. S. For external use. 

3 Tr. ratanhise or catechu, 50*00 [ § jss., 3 viij] ; 
Aqua destil., 500-00 [ I xvj] ; 
Alum, crudi, 5-00 [3 iv]. 
M. S. For external use. 

B Tannini puri, 5-00 [3iv]; 

Glycerini, 50-00 [ I jss., 9 viij] ; 
Aqua destil., 500-00 [ § xvj]. 
M. S. For external use. 

These preparations must be used by the patients at least 
three times daily. They may be injected into the vagina with 
a uterine or fountain syringe. By the aid of the speculum the 
nurse or the physician will be better able to apply the remedies 
to the diseased places. After the injections the vaginal walls 
should be wiped as dry as possible with cotton-wool, and, for 
the purpose of keeping them apart, the vagina should be tam- 
poned with pledgets of charpie, dipped in the astringent lo- 
tions. These should be changed every two hours, otherwise 
the blennorrhoic secretion with which they become saturated 
will undergo decomposition and irritate the mucous membrane. 
If the pledgets of lint have strings attached to them it will be 
quite easy to remove them from the vagina. 



GONORRHCEA, VENEREAL CATARRH. 83 

If the discharge, notwithstanding the frequent employment 
of the injections, does not cease — as is usually the case, espe- 
cially in elytritis papulosa — a speculum should be introduced 
into the vagina, and, after cleansing it of secretions, the mu- 
cous membrane should be cauterized with the solid stick of 
nitrate of silver, making circular sweeps with it as the specu- 
lum is being gradually withdrawn. The vagina should be 
immediately tamponed with dry absorbent cotton, but this 
must be removed in a few hours, and the injections again 
used. It is necessary to repeat these cauterizations of the va- 
gina every two or three days, and, failing to accomplish a cure 
in this way, pledgets of lint, dipped in a solution of alum or 
of bismuth, should be inserted and allowed to remain for two 
or three hours, and then followed by injections. [Quite re- 
cently a solution of bichloride of mercury (1 part to 5,000 or 
10,000 of water) has been used with excellent results.] 

3. Complications of Vulvo-vaginal Gonorrhoea. 

{a) Diseases of the Glands of Bartolini and their Ducts. 

We distinguish (1) disease of the gland and of the con- 
nective tissue surrounding it, and (2) disease of the duct itself. 
The first lesion is better known and of tener comes under treat- 
ment. Both originate usually from the extension of the vul- 
var inflammation to the walls of the excretory ducts and the 
gland itself. The disease, however, may also be produced by 
masturbation, since abscesses of the gland and of the labiae 
have been met with in virgins. Both affections generally oc- 
cur unilaterally. 

Inflammation of the gland is ushered in by febrile move- 
ment and constantly increasing pain in the affected labium, 
which swells up immensely. In the course of six or eight 
days a periglandular abscess forms, which finally bursts on the 
surface of the mucous membrane of the labium, or, in rare 
cases, a gangrenous condition ensues, producing an intensely 
fetid discharge. 

Inflammation of the excretory ducts runs either an acute 
or chronic course ; but even an acute inflammation causes only 
a moderate degree of pain, is unattended by fever, and does 



84 PATHOLOGY AND TREATMENT OF SYPHILIS. 

not give rise to any enlargement of the labium. A tenacious, 
mucous, sometimes also purulent discharge flows constantly 
from the excretory ducts, a condition that is liable to become 
chronic. If the discharge can not escape readily, the duct will 
become distended, ampulla-like, to its utmost capacity, and 
then some of the matter will be poured out periodically, or the 
bulging diverticulum that projects on the inner surface of the 
affected labium undergoes suppuration and ruptures. 

Periglandular abscesses occur more frequently than abscess 
of the diverticulum or of the excretory ducts. Abscesses of 
the excretory duct are more superficial than the periglandular 
ones. They are not so painful, burst and cicatrize sooner 
than the latter. The walls of the glandular abscess are un- 
even, shaggy,, markedly red, and bleed readily. The walls of 
the diverticulum are smooth and glistening. Catarrh of the 
excretory ducts is very obstinate, and often resists all kinds of 
treatment. 

Swelling and abscess of the glands of Bartolini may readily 
be mistaken for hernia labialis. The latter is generally lo- 
cated in the central part of the labium majus, and from that 
point it turns to the side of the vagina in the direction of the 
tuber ischii, and, with a finger in that canal, the direction of 
the tumor is readily followed. The diagnosis may be estab- 
lished beyond a doubt by examining the internal abdominal 
ring and by percussing the tumor. 

The other morbid alterations of the labia which are liable 
to be mistaken for inflammation and abscess of the glands of 
Bartolini are atheromatous and other cystic tumors of the 
labia. 

There is a disease of the labia, that occurs very rarely in 
Europe, and which consists in an enormous hypertrophy of 
one or both labia. This is known under the name of elephan- 
tiasis arabum pudendum. In the early stages of the disease 
the diagnosis may be established by the presence of a local, 
persisting, or frequently recurring erysipelas. In consequence 
of this erysipelas, the so-called lymphatic oedema, as is well 
knOwn, develops, and after a while causes the elephantiatic hy- 
pertrophy of the labia. In the further course of the disease, 
that form which has been hitherto described as elephantiasis 



GONORRHEA, VENEREAL CATARRH. 85 

glabra pudendorum may develop into the variety to which has 
been applied the term elephantiasis arabumfusca, on account 
of the glandular appearance of the affected parts of the skin, 
and the deep-brown color of the epidermis. 

In regard to the therapeutics of the disease, we wish to 
make the following observations : 

If the gland is affected, the patient, in the beginning of 
the disease, must keep perfectly quiet, and cold should be 
applied. When softening takes place, the compresses should 
be renewed less often, so that they may become warm and 
act as cataplasms, and the swelling lanced as early as practi- 
cable, and, if possible, externally, to prevent the lips of the 
wound from being infected by the vulvar or vaginal discharge. 
In catarrhal disease of the excretory ducts, cool sitz-baths and 
pledgets of muslin dipped in astringent solutions, such as tan- 
nic acid, zinc, or copper, laid upon the gland, have been found 
useful. A diverticulum that is in danger of undergoing sup- 
puration should be slit open and touched with lunar caustic 
once daily. Non-suppurating diverticula of long standing 
should likewise be slit open, and a weak solution of nitrate of 
silver (040 [gr. If] to water 100-00 [ § iij, 3viij]), should then 
be injected through the cut by means of an Anell's syringe. 

(b) Inflammation and Abscess of the Lymphatic Vessels in 
the Labia Jlajora and Ifinora, and of the Lymphatic 
Glands of the Inguinal Folds. 

These lesions occur especially in suppuration of one of the 
glands of Bartolini. They are due to the same pathological 
condition, and develop in the same manner as inflammation 
of other lymphatic vessels and sympathetic buboes (see Affec- 
tions of the Lymphatic Vessels and Glands in consequence of 
Soft Chancre). 

3. Uterine Gonorrhoea and its most Frequent Complica- 
tion : Erosions and Granulations of the Os Uteri. 

Uterine gonorrhoea occurs very rarely as an idiopathic dis- 
ease. As a rule, it is caused by propagation of the morbid 
process from the vagina. For that reason the cervical canal 
alone is found affected in most cases, and the body of the 



86 PATHOLOGY AND TREATMENT OF SYPHILIS. 

uterus becomes involved only when the disease has existed for 
a long time. 

Gonorrhoea of the cervical canal manifests itself partly by 
subjective and partly by objective symptoms. The subjective 
complaints are : Dull, unpleasant sensations, emanating from 
the pelvic cavity and radiating toward the lumbar region, fre- 
quent desire to micturate, and a general feeling of discomfort. 
The objective symptoms observed in an examination with a 
vaginal speculum are as follows : A gelatinous, collodion-like, 
ropy discharge oozes from the mouth of the uterus. This is 
excreted from the follicles lying between the plica palmatis 
of the cervical canal, tenaciously adheres to the secreting sur- 
faces, and reacts alkaline. During pregnancy it appears in 
cheesy flakes. This discharge corrodes the posterior lip of the 
cervix, and, in consequence, it often becomes streaked with 
bloody erosions. Uterine gonorrhoea seldom disappears entirely ; 
generally it merges into a chronic catarrh, because, as has been 
learned through experience, the mucous membrane of the cer- 
vix uteri, of all the genital mucous membranes, has the great- 
est tendency to become affected with chronic catarrh. In con- 
sequence of this chronic catarrh the follicles found there grow 
and become dilated into polypoid growths, which • sometimes 
protrude through the os uteri, become strangulated and drop 
off (ovula Nabothi). Should the morbid process involve the 
cavity of the uterus, irregular menstruation will ensue, it will 
become dilated, the secretions that have accumulated within 
become decomposed, and occasion the so-called physometra — 
i. e., accumulation of air within the uterine cavity. When the 
catarrh has existed for a long while, the mucous membrane 
undergoes various morbid changes. It is traversed by varicose 
vessels, studded with ecchymotic and discolored pigmented 
spots ; the ciliated epithelium is destroyed, the glands at the 
os excrete fat and hyaline matter instead of normal mucus, 
and become converted into cysts ; many of them when grouped 
together develop into polypi. The walls of the uterus become 
thickened ; prolapsus and displacement of the organ may take 
place. If the catarrh has extended to the Fallopian tube, ste- 
rility will either be the result, or the fecundated ovum remains 
in the vicinity of the os internum, and gives rise to placenta 



GONORRHCEA, VENEREAL CATARRH. 87 

praevia (Schroder). Infection with gonorrhoeal virus may oc- 
casion even metritis and parametritis. The digestive organs 
and the nutrition become unfavorably affected on account of 
these lesions, and functional disturbances of the uterus ensue. 
The appetite is diminished, vomiting occurs frequently, gastric 
catarrh ensues, followed by passive dilatation of the stomach. 
The patients become emaciated and anaemic. 

In regard to the question of the infecting property of the 
uterine discharge, we coincide, from personal experience, with 
the opinions of Cooper and Kicord, that it will produce gonor- 
rhoea in men, but of a, milder form. It will do this especially 
when it is profuse in quantity and contains many pus-cells, 
when the woman neglects to keep her genital organs clean, and 
when intercourse is repeated at short intervals with passionate 
ardor. This condition may obtain more frequently in illicit 
intercourse than among sedate married couples, and will also 
serve to explain those cases in which a woman suffering from 
uterine disease will communicate gonorrhoea to strangers who 
succeeded in infringing upon the rights of the husband, while 
the latter escapes infection. 

As a result of uterine catarrh, less frequently of severe, 
protracted vaginal catarrh, small erosions occur on the cervix 
and sometimes (especially in coexisting syphilis) in the cervi- 
cal canal. The coalescence of many of these erosions will 
form large bleeding spots, which are destitute of epithelium- 
cells. After the expulsion of the glands of Nabothi the ero- 
sions in the cervical canal may become converted into excavated 
minute ulcers, that heal by the formation of flat, grayish-white 
cicatrices. Not infrequently granulations, which vary in size 
from a millet-seed to that of a lentil, and which bleed readily, 
form upon the eroded surfaces. Hennig regards them as vas- 
cular papillae of the mucous membrane that have not yet cica- 
trized, or as new growths, which have sprung from the granu- 
lar proliferation of the papillae. In consequence of these 
erosions and granulations disturbances in the nerves of the sex- 
ual organs of the female, which manifest themselves in hyster- 
ical convulsions and the like, seem to be produced. 

So long as inflammatory phenomena in and about the uterus 
exist, sexual intercourse must be strictly interdicted, complete 



88 PATHOLOGY AND TREATMENT OF SYPHILIS. 

rest should be enjoined, the diet restricted, and cold applica- 
tions made over the abdomen and sacrum, free movement of 
the bowels procured, and whatever vaginal and uterine dis- 
charge is present should be carefully removed by injections of 
tepid warm water. If the inflammatory phenomena have al- 
ready disappeared, the cervical canal should be cauterized two 
or three times a week with the solid nitrate of silver, at the 
same time cooling sitz-baths prescribed, and the uterine douche 
employed. No injections of nitrate of silver should be made 
into the uterine cavity, because we have seen violent uterine 
colic and even inflammation of the uterus and of the ovaries 
produced by them. Healing of the erosions and granulations 
can only be achieved by persistent and zealous treatment of 
the primary catarrhal disease of the vagina or uterus. We 
have seen excellent results from penciling the eroded surfaces 
with a solution of nitrate of silver or copper. The imperfect 
digestion and assimilation, the anaemia and chlorosis, must be 
improved by the administration of good food, tonics, such 
as iron, wine, mineral waters, and baths, and a residence in 
the country. 

4. Urethral Gonorrhoea in the Female. 

Although the pathological lesions which are produced by 
urethral gonorrhoea are the same in the female as in the male, 
still it is not so dangerous nor is it apt to assume such a pro- 
tracted character in the former as in the latter. This is owing 
to the fact that the urethra of the female is shorter, fewer 
adjacent organs are so intimately connected with it, it does not 
participate in erections as in the male, and, being more ex- 
posed, it is more accessible to the application of remedies. 

The disease manifests itself in the same manner as in the 
male, by a tickling sensation at the meatus, which soon changes 
to a real pain, and is aggravated by urinating. The most sig- 
nificant symptom is the presence of a mucoid or muco-purulent 
discharge, which can be pressed out of the urethra by running 
the finger over it in the vagina from behind forward. This 
discharge should not be mistaken for the mucoid or puru- 
lent discharge of the inflamed mucous follicles which occur 
in the crypts on both sides of the female urethra. This fol- 



GONORRHCEA, VENEREAL CATARRH. 89 

liculitis can be cured in a few days by the use of astringent 
remedies. 

Among the accidents which may be associated with a female 
urethral gonorrhoea, dysuria is the most frequent, because, ow- 
ing to the shortness of the urethra, the neck of the bladder is 
more often involved than in the male. Haemorrhage in gonor- 
rhoea of the female urethra occurs very seldom, and is very 
slight. Inflammation of the inguinal glands is exceedingly 
rare, but warts and condylomata are remarkably frequent re- 
sults of the disease under consideration. 

The treatment of urethral gonorrhoea in the female is almost 
identical with that of the male. In women who will not submit 
to injections, cooling baths and the internal administration of 
the ethereal balsamic remedies should be ordered. In obstinate 
chronic urethral gonorrhoea the gradual introduction of the 
solid stick of argent, nitratis once into the urethra has accom- 
plished a cure in many cases. 

Gonorrhoea of the Rectum. 

Gonorrhoea of the rectum is a very rare disease. It may 
be produced in either sex by direct contagion, as in unnatural 
sexual intercourse (pederasty), or by want of cleanliness, the 
discharge from gonorrhoea of the genital organs running down 
to and coming in contact with the mucous membrane of the 
rectum. Hence this disease is met with more frequently in 
women than in men, the cause just mentioned exercising its 
effects with greater facility in the former. The skin of the 
perineum and around the anus in such cases is, as a rule, 
erythematous and excoriated. If folds of mucous membrane, 
in consequence of haemorrhoids, protrude from the anus, the 
parts will become infected with still greater facility by the 
discharge from the genital organs. 

The discharge from the rectum is pre-eminently purulent, 
has a disagreeable odor, and not infrequently is mixed with 
blood. It flows continuously, and is especially profuse before 
defecation and after the expulsion of flatus. It produces ex- 
coriations and Assures in the folds of the anus, especially in 
those cases in which infection has resulted from pederasty. In 
rectal gonorrhoea the patients suffer from pains only during 



90 PATHOLOGY AND TREATMENT OF SYPHILIS. 

defecation. During the intervals they complain only of a 
constant burning or itching in the anus, and a frequent desire 
to go to stool. In the most pronounced cases the mucous mem- 
brane of the anal aperture is reddened and swollen. 

We have never met with a case of chronic rectal gonorrhoea 
resulting from contagion, and it is probable that the discharge 
from other diseases occurring in this region, such as hsemor- 
rhoidal tumors, syphilitic moist papules, or chronic eczema, 
has been mistaken for that of gonorrhoea of the rectum. 
"Warts and condylomata are the most disagreeable effects of 
rectal gonorrhoea, for especially the latter may attain to such 
dimensions as to interfere with defecation. 

The treatment of gonorrhoea of the rectum consists of rest, 
general baths, or protracted sitz-baths, and injections of water 
into the rectum ; the movement of the bowels being prevented 
by a restricted diet, and the administration of opiates (and 
when that condition has been attained the rectum should be 
immediately washed out with clysters of water). For the 
purpose of checking .the secretion of pus, a one-per-cent solu- 
tion of tannic acid or of alum should be injected into the gut. 
In the intervals between the injections pledgets of lint dipped 
in the same solution should be inserted into the anal aperture. 
Excoriations or fissures should be touched with the nitrate of 
silver stick. 

Gonorrhoea of the Mouth and Nasal Cavities. 

We have never, either in hospital or private practice, met 
with a case of gonorrhoea of either of these cavities, though it 
is asserted in some of the older works that the disease occurs 
in both sexes, the mucous membrane of the nose and mouth 
being affected in the same manner as the conjunctiva. 

Gonorrhoea of the Eye. (Ophthalmia Gonorrhoea Blennor- 

rhoica.) 

By Docent Dr. Hock, of Vienna. 

The term ophthalmia blennorrhoica is applied to a disease 
of the conjunctiva of the eye, in which there occurs a profuse 
discharge of muco - purulent matter, attended by increased 
lachrymation, intense swelling, and redness of the mucous 



GONORRHCEA, VENEREAL CATARRH. 91 

membrane, proliferation of the papillary bodies, and sometimes 
actual ecchymosis ; in addition a serious inflammatory swelling 
of the eyelids and the adjacent integuments may occur, and, 
in some cases, affection of the eyeball itself, resulting in kera- 
titis and panophthalmitis. 

The disease begins with symptoms of a severe catarrh, 
which within a few days reaches its height. At this point it 
presents the following morbid picture : The eyelids, especially 
the upper one, are swollen to the size of a child's fist, and the 
integument of the lids and that surrounding them is reddened, 
tense, hot, and oedematous. The upper lid overlaps the lower, 
its cilia are agglutinated to one another and to the skin of the 
lower lid by thick, yellowish matter, some of which has dried 
and formed crusts. If after the removal of the crusts an at- 
tempt is made to raise the upper lid with the fingers, a quan- 
tity of yellowish matter gushes out, the lid becomes everted, 
and the intensely swollen conjunctival mucous membrane 
bulges out. In the tarsal parts the conjunctival connective tis- 
sue is seen to be of a deep-red color and intensely swollen, the 
papillae congested to such a degree as to give it a velvety or 
warty appearance ; sometimes the latter may be seen with the 
naked eye as minute excrescences, between and upon which 
a grayish-yellow matter has accumulated, which occasionally 
solidifies and acquires the character of a false membrane. If 
the lids are separated by the aid of an eye-speculum, the ocular 
conjunctiva, the caruncle, and the semi-lunar fold are seen to 
be red, thickened, and uneven, the former swollen and forming 
around the cornea an oedematous, transparent florid or livid 
wall like a parapet, under which the cornea is buried, its cen- 
tral part only being visible. Generally the patient also suffers 
from febrile movement. 

Of the causes of gonorrhoeal ophthalmia it is only necessary 
to mention here the direct transportation of gonorrhoeal matter 
to the conjunctiva by the fingers of the patient and of the in- 
fection of the sound eye with the discharge from the diseased 
eye. Some authors, Neisser among others, also claim to have 
found micrococci in the discharge of eyes affected with blen- 
norrhcea. 

Ophthalmia blennorrhoica runs an acute course ; it gener- 



92 PATHOLOGY AND TREATMENT OF SYPHILIS. 

ally reaches its end in three or four weeks. Although in some 
cases the disease runs a most violent course, attaining its high- 
est intensity in thirty-six or forty-eight hours, resulting in 
ulceration and perforation of the cornea, yet in others the symp- 
toms are very mild and slower in their progress, and the disease 
yields much more readily to appropriate treatment. Hence a 
complete restitutio ad integrum is observed only in the milder 
class of cases. It is true that even in the severer class a cure 
will be achieved, but always with more or less marked cicatri- 
zation of the cornea, anterior synechia, partial corneal staphy- 
loma, and cataract. Often, however, it results in complete 
phthisis cornese, panophthalmitis with consequent atrophy of 
the eye-bulb. Sometimes proliferation of the papillae remains 
after a blennorrhcea, a condition which, in some cases, is ob- 
served even during the progress of the disease, though in others 
not until it has run its course. (Chronic blennorrhcea, trachoma, 
conjunctivitis granulosa.) 

Treatment of Gonorrhceal Ophthalmia. 

(1) Immediately after the conjunctiva has been infected 
with gonorrhceal matter it should be washed thoroughly with 
some antiseptic preparation, such as a hve-per-cent solution of 
natr. benzoic, or a two-per-cent solution of boracic acid, or, for 
want of either, with pure water, or with a two-per-cent solution 
of argent, nitric, for the purpose of checking the action of the 
infecting matter. 

(2) At the beginning of the disease the patient should be 
put on a strictly antiphlogistic diet, and the eye should be re- 
peatedly washed with the antiseptic solutions just mentioned. 
In contractions of the pupil, atropine (0*10 [gr. 1 £] to water, 
30-00 [ g j]) in solution should be dropped into the eye. 

(3) If the blennorrhoic process is very intense, the hrst care 
of the physician should be to protect the sound eye from in- 
fection with the gonorrhceal matter by bandaging it carefully 
and keeping the patient in a proper position (in this case he 
will be compelled to stay in bed). 

(4) Zealous cleansing of the eye with cold water or antisep- 
tic lotions, application of ice, local abstraction of blood during 
exacerbations, laxatives, and cooling drinks and low diet should 



GONORRHCEA, VENEREAL CATARRH. 93 

be strictly enforced. Should the chemosis of the conjunctiva 
and the swelling of the eyelids be very great, the external can- 
thus must be divided ; the lower lid, which is now released, 
may then be everted by means of Gaillard's snare, and the 
haemorrhage that follows may be allowed to go on for a little 
while. 

The most important part of the treatment of the eye, how- 
ever, is the use of caustics. It consists of the introduction of 
a solution of nitrate of silver (two to four per cent) or of the 
solid stick, composed of nitrate of silver and nitrate of potash 
(equal parts, or one of the former to two of the latter) fused 
together. The entire 'palpebral conjunctiva should be pen- 
ciled with one of these agents once every twenty-four hours, 
the excess of the caustic, neutralized with a solution of salt 
and the chloride of silver, which thus forms, washed away with 
water. 

In cases of intense turgescence of the palpebral conjunctiva 
and in chemosis of the ocular conjunctiva great benefit will be 
derived from scarifications of the membrane, the tension of 
the swollen tissues and the stasis of the circulation being there- 
by relieved. Should the cornea become opaque, or ulcers form 
on it, atropin in solution must be dropped into the eye several 
times a day, but not simultaneously with the caustic. In im- 
pending perforation of the cornea, or when the perforation 
has already taken place with its consequent effects, in prolajDSUs 
of the iris, etc., the treatment indicated for these conditions 
must be resorted to. 

The Effects or Sequelae of Gonorrhoea in general and of Urethral 
Gonorrhoea in particular. 

By the term effects or sequelae of gonorrhoea we under- 
stand morbid lesions which generally remain a long while 
after the disease that has produced them has disappeared. These 
morbid lesions are such as are exclusively produced by gonor- 
rhoea in the urethra itself and beyond its sphere. To these 
belong gonorrhceal gout or rheumatism, and stricture of the 
urethra and its effects. Again, they constitute those morbid 
processes which originate partly from any kind of gonorrhoea, 
but especially in consequence of the irritation of the gonor- 



94 PATHOLOGY AND TREATMENT OF SYPHILIS. 

rhoeal discharge upon the adjacent integument and mucous 
membrane. These include condylomata. 

Gonorrheal Rheumatism. 

Gonorrheal rheumatism or gout is one of the rarest 
complications of gonorrhoea in both sexes. Writers on the 
subject are not yet agreed. In regard to its nature and con- 
nection with the gonorrhoeal disease, some maintain that it 
is purely an accidental complication. Others, again, say that 
every physiological and pathological process in the genital 
organs of both sexes may light up rheumatism, and therefore 
call it " genital rheumatism." Were this the case, rheumatic 
affections would be much more frequent in the female ; but, 
on the contrary, gonorrhoeal rheumatism only occurs in the 
latter, when attacked by gonorrhoea of the urethra — one of 
the rarest gonorrhoeal affections in women. The so-called old- 
style unicists claimed that gonorrhoeal rheumatism is a rheu- 
matic diathetic disease, that has originated in consequence of 
the absorption of the gonorrhoeal virus, which they compare to 
the rheumatic pains occurring in syphilis. Other writers are of 
the opinion that the gonorrhoeal process gives rise to a chloro- 
anaemic condition of the entire system that leads to lesions of 
nutrition, produces peculiar secondary diseases of the serous 
membranes, the scrotum, joints, synovial sacs, etc. It should 
not be forgotten that rheumatic diseases not only occur in 
catarrhal affections of the urethra occasioned by non-virulent 
agents, but also in those produced by mechanical causes. 
Hence gonorrhoeal rheumatism would not be so exceedingly 
rare if there were such a condition as a blennorrhoic diathe- 
sis ; and, in addition, preputial, vulvar, and vaginal gonorrhoea 
should likewise be capable of causing rheumatoid disease. 
This, however, is not the case. In sixty-two cases of gonor- 
rhoea, Fournier observed only one case of rheumatism, and even 
this is too high a number, when it is remembered that many 
cases of gonorrhoea get well without the aid of a physician. 
We agree, therefore, with Fournier, that rheumatism originat- 
ing from urethral gonorrhoea is occasioned less by the blen- 
norrhagia than by the individual pathological condition of the 
urethra, an irritation of it, like the occasional production of 



GONORRHCEA, VENEREAL CATARRH. 95 

articular inflammations by the introduction of a catheter or 
sound into the urethra. Hence, only certain persons are at- 
tacked by gonorrhoeal rheumatism, and are afflicted by it as 
often as they contract a gonorrhoea. 

We have only met with muscular and articular rheuma- 
tism ; never with rheumatic inflammations of the synovial 
membranes or of the periosteum, nor with rheumatic affec- 
tions of the sciatic nerves. The knee-joint was most fre- 
quently affected ; still, any other joint in the body is likely to 
suffer. One joint only, as a rule, is attacked at a time. 

In some cases the rheumatic affection is noticeable at the 
very beginning of the urethral gonorrhoea. In many cases, 
however, the rheumatism does not appear until the urethral 
disease has become torpid. Gonorrhoeal rheumatism originates 
suddenly. The joint was perfectly well a few hours before the 
attack came on. If the arthritic rheumatism appeared almost 
simultaneously with a purulent gonorrhoea, the inflammation 
of the joint will develop very rapidly and cause marked swell- 
ing of the soft parts which surround the joint. These kinds 
of joint-affections keep pace with the gonorrhoea, and, like it, 
disappear under judicious treatment in about six or eight 
weeks. But if the joint-disease appears after the gonorrhoea 
has existed several weeks, the former will then develop less 
rapidly, and, like the urethral disease, assume a chronic, pro- 
tracted character that obstinately resists the most appropriate 
treatment. 

Chronic, like acute gonorrhoeal articular rheumatism, is 
ushered in by febrile phenomena ; in the acute joint-affection 
they are, however, much more violent. In the acute disease, 
the fever as a rule subsides in about six or eight days. If the 
articular disease does not assume a favorable course, the fever 
will remain, though at a lower degree. In chronic gonorrhoeal 
rheumatism, the fever, it is true, lasts longer, but it is less 
severe. It, however, rises just as in the acute articular rheu- 
matism, whenever an exacerbation of the articular affection 
takes place. 

No exudation into the capsule of the joint can be detect- 
ed in all cases ; but in some an actual hydrarthrosis of con- 
siderable dimensions with characteristic fluctuation develops. 



96 PATHOLOGY AND TREATMENT OF SYPHILIS. 

The integument over the swelling of the affected joint, as a 
rule, is neither reddened nor thickened ; in some cases, how- 
ever, an erythema glabrum develops upon it. The affected 
joint is sensitive to such a high degree that the least move- 
ment causes the patient the most intense pain. 

The serous exudation that has accumulated in the cavity 
of the joint may, under favorable circumstances, be absorbed. 
Under the influence of a constitutional disease, however — for 
instance, scrofula or tuberculosis — the absorption of the exuda- 
tion is not only delayed, but a permanent articular dropsy, hy- 
drarthrosis, arthrocele blennorrhagica, tumor blennorrhagicus, 
originates in some, though exceedingly rare, cases. Some very 
reliable authors mention a still rarer termination of gonor- 
rhoeal rheumatism — namely, suppuration in the joints. A total 
or partial union of the joints, ankylosis, occurs oftener than 
the two preceding terminations already mentioned. Gonor- 
rheal rheumatism has a settled character — i. e., it does not 
travel from one joint to another. We have never seen it at- 
tended by pericarditis or endocarditis. The articular disease 
exercises no influence upon the gonorrhoea! discharge, neither 
diminishing nor increasing it; still, we have noticed that 
chronic and acute articular rheumatism subside only when the 
last traces of the gonorrhoea have disappeared. 

The prognosis of gonorrhoeal rheumatism, in general, is 
favorable, the joints, as a rule, recovering fully their normal 
condition. Ankylosis occurs very rarely — usually in the knee- 
joint alone. Hydrarthrosis most frequently originates in the 
knee-joint. Suppuration of the joints may cause death by 
pyaemia. The articular affection does not last the same length 
of time in all joints ; the disease of the shoulder-joint does not 
last nearly as long as that of the knee- and ankle-joints ; disease 
of the joints of the phalanges disappears more quickly than 
that of other joints. Chronic gonorrhoeal disease of the joints 
generally lasts many months; in tuberculous and in badly 
nourished persons, sometimes more than a year. 

The articular disease requires absolute rest and antiphlo- 
gistic treatment, such as cold applications and leeches to the 
affected joint. Hypodermic injections of morphia will be re- 
quired to assuage the intense pains. When the febrile phe- 



QONORRHCEA, VENEREAL CATARRH. 97 

nomena are very high, the patient should be subjected to a 
strict diet, cool or acidulous drinks only allowed, and a daily 
movement of the bowels secured. If hydrarthrosis has formed, 
cold or warm applications should be made, with or without 
ammonia, 50*00 [J jss., 3iv] to water 1000*00 [Oij], according 
to the congestive condition of the articular swelling. When 
no inflammatory redness is present, iodine, or some of its com- 
pounds, like the following, may be used locally : 

3 Iodureti plumbi ; 

Ext. belladonna, aa 5'00 [3iv] ; 
Ung. litharg., 100-00 [ § iij, 3 ij, 3ijl; 
Ung. elemi q. s. ut tiat emplastr. molle. 
S. To be spread upon a piece of chamois-leather or muslin, of the 
thickness of the blade of a knife, and laid upon the affected joint. 

In hydrarthrosis of the knee we have occasionally seen good 
results from the use of a compress-bandage, made of plaster of 
Paris, starch, or water-glass. In other cases a plaster composed 
of gum-ammoniac and acetum scillse is beneficial. In cases of 
chronic hydrarthrosis, good results are sometimes derived from 
the sulphur thermal baths. The treatment of suppuration of 
the joints, of fistulge, necrosis, etc., belongs to the domain of 
surgery. The existing gonorrhoea must be treated with appro- 
priate local and internal remedies. Constitutional diseases, of 
whatever nature, such as scrofula, tuberculosis, syphilis, etc., 
demand careful and special attention. 

Condylomata ; Vegetations ; Spitze or Moist Warts. 

One of the most frequent morbid changes that are met with 
in consequence of gonorrhoea, in both sexes, is the formation 
of warts, or cauliflower-like growths, on the genital organs and 
their vicinity — on places where pus, sebum, or gonorrhceal 
discharge is allowed to remain for some time, and, owing 
to its decomposing effects, the integument or mucous mem- 
brane becomes so irritated and macerated that the epithelial 
layer is destroyed. On these places hyaline granules, of the 
size of a pin's head, form, which gradually assume the shape 
of a cone or cock's comb, resembling more or less a dendritic 
vegetating growth. After these vegetations have attained a 
certain size they grow very rapidly. The less the parts on 
■7 



98 PATHOLOGY AND TREATMENT OF SYPHILIS. 

which these cauliflower excrescences grow are cleansed, the 
more quickly and abundantly these vegetating excrescences 
will sprout, the more profuse and succulent they will be, and 
the more readily will they bleed. The cleaner and drier the 
parts on which these warts are situated are kept, the more 
quickly will those that already exist shrink, and the less likely 
are new ones to sprout. If one of these excrescences is cut off 
at its base, two bleeding points may be noticed on the cut sur- 
face, one of which corresponds to the entering, the other to the 
emerging capillary vessel. 

Histogenetically regarded, two directly opposite views pre- 
vail in reference to this lesion. While some writers look upon 
the growth as a hypertrophic proliferation of the tegumentary 
papilla, others hold that the origin of condyloma is mainly due 
to an exuberant growth of the cells of the rete Malpighii, at 
the expense of the tegumentary papillae, whose cells spread 
their prolongations not only upward but also downward, like 
a cock's comb, forcing their way in between the papillae. The 
epidermal cells have a very slight tendency to undergo a cor- 
neous change, and even the uppermost layers retain the succu- 
lent condition of the Malpighian cells. The whole is covered 
by a very thin corneous layer. No nervous filaments have yet 
been detected in the exuberant growth spoken of. 

Warts or condylomata are most frequently met with upon 
the glans penis, especially in the fossa coronaria, on the corona, 
on the foreskin, especially its internal or mucous membrane ; 
on the frenulum, on the large and small labia, in the urethra 
and vagina, on the os uteri, at the lower part of the rectum, 
on the navel, on the skin of the genital organs generally, and 
in the neighborhood of these organs. If the condylomata are 
situated upon the integument or mucous membrane of the co- 
rona glandis or prepuce, in a person with phimosis, they will 
be reddened and softened like raw flesh, owing to the fomen- 
tation they are constantly subjected to. If they are situated 
upon exposed places they will be dry, corneous, yellowish or 
whitish in color. The vegetations that are situated upon the 
mucous membrane of the vagina are so brittle that they are 
often broken off by the introduction of the speculum. 

Condylomata assume a different shape according to their 



GONORRHCEA, VENEREAL CATARRH. 99 

location. If the warty growth is compressed between two 
opposing surfaces, the so-called cock's-comb-like vegetation will 
originate. If the condyloma is subjected to pressure from 
above, the excrescence will gradually be flattened and assume 
the form of a mushroom. On places where the growth may 
freely develop, linear pedunculated, strawberry-, mulberry-, or 
cauliflower-like excrescences will originate. If many such 
growths are in close juxtaposition, they will mutually compress 
one another, and acquire smooth surfaces, which are separated 
by narrow fissures, and form clusters similar to the blossoms 
of thyme ; hence the old writers called them acrothymion, or 
thymos. These warty efflorescences cause a good deal of me- 
chanical obstruction, and, moreover, owing to the alteration 
which they undergo in their course, exercise an unfavorable 
influence upon the general system. Thus, they may occlude 
the preputial opening and the meatus urinarius, preventing the 
removal of the smegma from beneath the foreskin, the flow of 
the urine, and the ejaculation of the semen. In a similar man- 
ner the female urethral meatus and the vulvar aperture may 
become occluded by pointed condylomata, and micturition and 
coitus may likewise be rendered difficult. By the growth of 
large condylomata around the anus, in both sexes, defecation 
may become very difficult and painful. Those condylomata 
that are situated upon places where they are subjected to con- 
tinual friction or pressure readily become gangrenous. Ordi- 
nary condylomata may be mistaken for epithelial carcinoma, 
for the cauliflower tumor of Clark on the os uteri, and for the 
flat specific condylomata. The manner of development, the 
course, the attendant phenomena, the result of the treatment 
that has been resorted to, will aid the physician in forming a 
correct diagnosis. It is very easy to mistake vegetations for 
the flat syphilitic condylomata, for both kinds maybe met with 
at the same time. 

Experience as well as experiment has proved that condy- 
lomata are transmissible by direct contact. 

Condylomata possess remarkable powers of reproduction: 
one shoot may be cut off, and five others will grow in its place. 
The small warts, not bigger than a millet-seed, and sprouting 
close to each other, are the most difficult to get rid of. 



100 PATHOLOGY AND TREATMENT OF SYPHILIS. 

Pedunculated warts may be removed with Cooper's scissors, 
or tied and allowed to fall off. When the warts are cut off, 
enough mother-tissue should be taken away with them. The 
wounds should be moistened with a solution of ferrum chlo- 
ridum, to check the bleeding and prevent the future growth 
of the condylomata. The local application of a solution of 
chloride of iron is especially useful in large aggregated condy- 
lomata ; the astringent action of the iron contracts them, and 
prevents bleeding if they are subsequently cut off. Tincture 
of iodine acts in a similar manner, but far less effectively. 
The concentrated acids very seldom answered our expectations. 
Solutions of corrosive sublimate in spirits of wine, or in sul- 
phuric ether, 0*5 [grs. viij] to 50*00 [§ jss., 3iv], rendered 
much better service. Plenk's paste acts more intensely than 
the solution of mercury ; it may be prepared in the follow- 
ing manner : 

]J Sublim. corros. ; 
Alum crudi; 
Carbon, plumbi ; 
Oamphorss ; 
Spirit, villi ; 

Aceti vini, aa 5 -00 [3iv]. 
M. S. For external use. 

The precipitate is applied to the warts with a eamel's-hair 
brush. Plenk's paste, however, is apt to produce unpleasant 
effects, such as intense oedema and mercurial stomatitis. 

The hard, dotted warts are readily removed by the use of 
arsenious acid or iodide of arsenic mixed with mercurial oint- 
ment. For this purpose we prescribe : 

]$ Acidi arsenicosi, 0-20 [grs. iij] ; 
TJng. hydrarg., 5*00 [3iv] ; 
M. Ft. ung. 

1$ Arsenic, iodat., 0-20 [grs. iij] ; 
Ung. hydrarg , 5*00 [3iv] ; 
M. Ft. ung. 

A lump of salve, of the size of a lentil, is applied to the 
warts several times a day upon some wadding. Moist, secret- 
ing condylomata are sometimes made to shrink by dusting them 



GONORRHCEA, VENEREAL CATARRH. 101 

with pulverized alum, calomel, oxide of iron, sulphate of iron, 
and savin-powder. If the prepuce is phimosed, it mast be 
split or amputated, in order to expose the condyloma. Large 
aggregations of warts on the labia are most appropriately treated 
by ligation or with the galvano-cautery, or the thermo-cautery 
of Paquelin. In tying condylomata, not more than one root 
should be embraced in each ligature, because the tying of many 
large aggregated clusters of excrescences has, in some hi stances, 
produced tetanus and terminated in death. But, whatever 
method be selected for the removal of condylomata, cleanliness 
and keeping the parts dry should always be enforced. Cold 
applications alone, constantly and properly made, have caused 
the vegetation to fall off in cases that have resisted repeated 
cauterizations and excisions. 

Strictures of the Urethra. 

One of the most frequent sequelae of urethral gonorrhoea 
in the male is stricture of the urethra. The contraction may 
take place at any part of the urethra, save in the prostatic por- 
tion. An obstruction to the passage of a catheter or sound 
only forms in the prostatic portion of the urethra when the 
prostate, from inflammation, hypertrophy, or swelling, has be- 
come so large that it compresses the lumen of the urethra from 
without inward. We may classify strictures in the other parts 
of the urethra, according to Dittel, as spastic, inflammatory, 
and organic varieties. By the term spastic strictures we un- 
derstand transient constrictions of the lumen of the urethra, 
occasioned by spasmodic contractions of the muscular apparatus 
of that canal. One can easily convince himself of the existence 
of such a stricture by attempting to introduce a large sound. 
It will be grasped and held tight at some point, but by patiently 
waiting, refraining from exercising the least pressure with the 
instrument, and allowing it to lie quietly for a while in the 
urethra, it will soon, almost of its own accord, slip into the 
bladder. Some very good surgeons deny the existence of this 
form of stricture of the urethra. Many prominent authors, 
however, such as Esmarch, Dumreicher, Albert, Hunter, and 
others, maintain with justice that this form of urethral con- 
tractions does occur. The spasm mostly affects the muscular 



102 PATHOLOGY AND TREATMENT OF SYPHILIS. 

tissue surrounding the membranous portion of the urethra, the 
transverse perinei profundus muscle; in other instances the 
spasm attacks the urethra at various points and occasionally 
may become so intense that it is not possible to withdraw the 
sound, which is already partially in the urethra, giving one the 
impression that it is firmly held there. 

Transient strictures due to spasmodic contractions of the 
urethra manifest themselves by the patient being attacked by 
a sudden desire to urinate, after having emptied the bladder a 
little while before without any difficulty. The urine, after 
much pressure, pain, and a burning sensation, comes away in 
drops, or is expelled spasmodically (dysuria), or it can not be 
voided at all (ischuria). These strictures may occur even in 
persons who never snfiered from gonorrhoaa, after having had 
their feet wet, or after indulging too much in imperfectly 
fermented or still fermenting drinks, new beer, etc. These 
symptoms, however, almost always accompany organic strict- 
ures of the urethra. In regard to the treatment of this condi- 
tion much benefit will be derived from belladonna supposito- 
ries, moist warm applications and warm sitz-baths twice daily. 
In addition, the patient must abstain absolutely from the use of 
all kinds of drink that are liable to irritate the bladder, such as 
champagne, cider, new beer, and fresh wine. In regard to the 
inflammatory strictures we will say briefly that they are pro- 
duced by thickening and swelling of the mucous membrane. 
These strictures develop in consequence of gonorrhoea, or after 
operations on the rectum or on the external genital organs in 
the female. 

The organic strictures of the urethra may very properly be 
divided, as proposed by Dittel, into two chief groups. One 
main group is occasioned by proliferation of the connective 
tissue, the other by the development of a structure heterolo- 
gous to the tissues of the urethra. "We will only speak here 
of the first form, that form which occurs so frequently as a 
result of gonorrhoea. Dittel briefly calls this kind of urethral 
stricture, when it is in a state of exuberation, callous stricture ; 
when in a state of shrinking, atrophic stricture. The symp- 
toms of organic stricture of the urethra are as follows : The 
stream of urine becomes thinner and changes its direction. 



GONORRH(EA, VENEREAL CATARRH. 103 

Simple division of the stream of urine is of no pathognomonic 
value, and in most instances is occasioned by the agglutination 
of the meatus with mucus. The bladder is never entirely 
emptied of its contents, and in consequence thereof the patient 
is compelled to urinate oftener. That part of the urethra be- 
hind the stricture is often dilated like a diverticulum, and, if 
the stricture lasts for a long while, rupture of the urethra may 
occur, terminating in infiltration of urine and fistulous open- 
ings behind the stricture. In long-standing stricture of the 
urethra, catarrh of the bladder will develop, and may be fol- 
lowed by pyelitis, nephritis, and death. 

In regard to the form of the stricture, it is sufficient to say 
that it varies very much. It may be a sharply defined pro- 
jection, or only a ridge stretched directly across the lumen of 
the urethra ; or, again, a resisting, hypertrophic circular band. 
Sometimes caruncle-like granulations form ; and, finally, the 
contractions, in some cases, are produced by angular deviation 
of the urethra from its normal course, in consequence of cir- 
cumscribed lateral atrophy of the connective tissue surrounding 
the urethra. 

Strictures in the membranous portion often occur from the 
cicatrization of gonorrheal ulcers that have burrowed and un- 
dermined the mucous membrane. In like manner, adhesive 
inflammations may give rise to strictures in the urethra. 

Strictures are most frequently found in the membranous 
portion or in the anterior part of the pendulous portion. Oc- 
casionally two and even three strictures are found behind each 
other. 

For the purpose of diagnosing a stricture, the physician, in 
the first place, should get a view of the stream of urine, the 
patient being required to urinate in his presence. A perfectly 
clear stream of urine, which does not deposit any sediment, 
excludes a severe stricture. The patient should not be allowed 
to urinate directly before it is proposed to examine him with 
instruments. The examination is best conducted with the 
patient lying on his back, while the physician stands at his 
left side. Having warmed and oiled the sound (which should 
be as large as will enter the meatus), and retracted the fore- 
skin, the physician, holding the penis between the thumb, in- 



104 PATHOLOGY AND TREATMENT OF SYPHILIS. 

dex, and middle fingers of his left hand, and the instrument be- 
tween the thnmb and index-finger of his right hand, inserts the 
instrument into the meatus, the little finger of his right hand 
resting upon the body of the patient for support, thus afford- 
ing the hand rest and security. In this way he guides the 
instrument as it passes into the bladder. The penis is drawn 
up on the sound more than the instrument is pushed into the 
urethra. If an obstruction is encountered, the next smaller- 
sized sound should be tried ; and if a number eight sound does 
not pass, it will be better to resort to English gum-elastic or 
conical bougies. 'No metallic instruments smaller than number 
eight should be used, on account of the imperfect sensation 
which they transmit to the fingers, and the risk of making a 
false passage with them. Conical elastic instruments without 
bulbs are not worthy of recommendation, because they easily 
become imprisoned in some of the dilated follicles and cause 
irritation. If no sound can be passed through the stricture, an 
attempt should be made to pass an English elastic catheter ; and 
if this too fails, it will be necessary to resort to the use of fili- 
form bougies. In this case it will be well to try the procedure 
recommended by H. von Zeissl, which consists in filling the 
urethra with filiform bougies well oiled, and pushed clear down 
to the stricture, and then a trial should be made carefully with 
one after another to pass it through the stricture. One of 
them will then surely go through. Having succeeded in pass- 
ing the instrument at last through the entire length of the 
urethra, it will then be necessary to map out the proper course 
of treatment to be pursued. There are three methods of treat- 
ment, namely, slow or gradual dilatation, rapid dilatation, and 
division of the stricture. 

We only practice gradual dilatation and division of the 
stricture from without inward. We will first speak of the 
gradual dilatation. If the stricture is so small as to permit 
only a filiform bougie to be passed, a catgut bougie should be 
inserted, and allowed to remain in the urethra until it has be- 
come distended to its utmost capacity. If, during this time 
(half an hour to an hour), no unpleasant symptoms have been 
produced, an effort should be made to pass a fine English gum- 
elastic bougie. If we have finally succeeded in passing this 



GONORRHCEA, VENEREAL CATARRH. 105 

instrument, no further trials should be made at the time ; but 
the next day another effort may be made, commencing with 
the size left off on the previous day, and afterward using 
larger bougies gradually. Having finally succeeded in passing 
through a thin gum-elastic catheter, it should be left in the 
bladder, and tied in for twenty-four hours, if no unpleasant 
effects are produced. In this way dilatation is accomplished 
much more rapidly ; on the next day a larger instrument may 
be introduced, and so on, till the urethra admits the largest- 
sized sound. If a catheter is retained in the urethra, the urine 
should be drawn off every three hours, or as soon as ischuria 
comes on. Should symptoms of nervous irritation, urethral 
fever, or other unpleasant signs manifest themselves, it will be 
necessary to remove the instruments immediately. In regard 
to the symptoms of irritation produced by the introduction of 
an instrument into the bladder, we have the following observa- 
tion to make : Some persons do not tolerate the passing of an 
instrument into the urethra even if they have no stricture 
whatever. A little while after the instrument is inserted they 
are seized with a chill, followed by high fever, violent head- 
ache, or at least a sensation of discomfort in the head. These 
phenomena generally soon disappear entirely ; in some cases, 
however, they often reappear, sometimes lasting several weeks, 
till the patient either becomes habituated to the passage of the 
sound, or has been cured of his stricture. This violent irrita- 
tion, which Dittel calls nervous reaction, may be allayed by 
small doses of morphine, administered from half an hour to 
two hours before using the instrument. Should this fail, and 
the nervous phenomena come on with equal severity after each 
attempt at dilatation, the gradual dilatation of the stricture will 
have to be abandoned and external urethrotomy performed. 
If the urethra has been injured during the introduction of an 
instrument, a similar state of reaction, which Dittel calls surgi- 
cal fever, is liable to ensue. The latter in reality differs only 
from the nervous reaction by the fact that the patients did not 
suffer from any phenomena of irritation during the previous 
dilatations. The phenomena of irritation are, however, most 
violent when the kidneys and bladder are seriously diseased at 
the same time. This affords us a guide in treatment. If the 



106 PATHOLOGY AND TREATMENT OF SYPHILIS. 

introduction of an instrument into the urethra is tolerated, it 
may be allowed to remain in it a long time. If reaction takes 
place, or the patient is already advanced in life, we will have 
to be content with keeping the instrument in the urethra for 
a short time only, from five minutes to half an hour, and to 
introduce it only every other day. It is absolutely neces- 
sary, before beginning the treatment of a stricture, to make a 
careful microscopical and chemical examination of the urine. 
Pyelonephritis, for instance, is liable to become aggravated so 
rapidly, even if the dilatation is practiced with the utmost 
care, that death ensues in a very few days. Hence we practice 
external urethrotomy — the so-called houtonniere — in patients 
who do not tolerate the dilatation of the stricture with instru- 
ments. Gradual dilatation, to be successful, requires a year's 
after-treatment, i. e., the constant introduction of instruments. 
If this is discontinued, even for a short time, the stricture con- 
tracts again, and the treatment must be renewed. 

We will describe the two methods of division of a urethral 
stricture, viz., division of the stricture from without inward 
and from within outward — urethrotomia externa et interna. 
The division of the stricture from without inward is now per- 
formed in those cases in which the stricture is so tight that 
even the finest filiform bougie can not be passed, or in those 
in which febrile or nervous reaction ensues whenever a dilating 
instrument is introduced. For the details of this operation, 
we refer the reader to the special works on surgery. We have 
obtained excellent results from the boutonniere. We have 
discarded entirely internal urethrotomy and rapid dilatation. 
Both methods, it is true, relieve the patient from his stricture 
very quickly, but they expose him to the great danger of infil- 
tration of urine, and, like the harmless gradual dilatation, re- 
quire a long after-treatment. The dangerous character of this 
operation, and the fact that strictures after having been divided 
return in as severe a form as before the operation, if no after- 
treatment is carried out, and that a certain degree of pervious- 
ness of the urethra is always presupposed to exist for the pur- 
pose of admitting the necessary instruments, are the reasons 
why we never perform this operation. 

[By injecting a syringeful of olive-oil into the urethra, so 



GOJSTORRSCEA, VENEREAL CATARRH. 107 

as to distend it fully, the passage of the bougie will often be 
materially facilitated. Sometimes injections of ice-water have 
served a very useful purpose by causing contraction of the en- 
gorged tissues, and thus rendering the strictured parts per- 
meable to a bougie or catheter. In this connection, I would 
add that in retention of urine coming on suddenly, in conse- 
quence of engorgement of the tissues following a debauch, 
coitus, or exposure to cold, a hot bath, with a full dose of mor- 
phine administered internally, has often accomplished excellent 
results. When these remedies fail, it will be necessary to 
anaesthetize the patient for the purpose of introducing a cathe- 
ter to draw off his urine. If time permits, I often succeed, by 
blistering the peringeum, in reducing the engorgement of the 
strictured part of the urethra to such a degree that bougies or 
catheters pass with comparative ease. Mr. Tevan, of London, 
resorts to leeching the peringeum for the same purpose. 

In regard to internal urethrotomy, in properly selected 
cases the operation will be of signal benefit, especially when 
time is an element to be considered. Where the method of di- 
lating a stricture with sounds or bougies requires many months, 
internal urethrotomy will achieve the same result in as many 
weeks ; though, to be sure, the after-treatment with sounds can 
not be dispensed with after this operation any more than in any 
other method.] 



SECTION II. 

SOFT CHANCRE OR CHANCROID. 

The term " chancre " has generally been applied to an nicer 
the origin of which has long been ascribed to a contagions spe- 
cific matter, which was itself reproduced in the nicer. 

Up to the present time we have not succeeded in establish- 
ing a clear, scientific, and comprehensive definition of that ulcer 
which is commonly called (soft) chancre. 

"We know no more regarding the contagious element which 
is capable of giving rise to soft chancres than we do of the na- 
ture of contagions in general. The conception of the contagion 
is an abstract one. We only know that, if a minimum quantity 
of the discharge from such an ulcer comes in contact with liv- 
ing cutis or mucous membrane, it will produce in a short time 
at that place an ulcer analogous to the parent-ulcer, and from 
this fact we conclude that the discharge possesses contagious 
properties. 

Uninjured epidermis and epithelium-cells are a protection 
against the action of the chancre-virus. There is no special 
congenital predisposition or susceptibility to the action of the 
chancre-poison, neither is there any particular immunity or 
freedom from it. All warm-blooded animals are susceptible 
to the action of the chancrous virus. The effect of the poison 
of the soft chancre is said to be markedly increased when a 
difference exists in the superiority of the race between the 
infected and infecting. Newly-born children and nurslings 
resist infection by a chancroid less than adults, possibly be- 
cause their cutis is more richly supplied with blood-vessels. 
Different tissues are also differently affected by the contagion. 
Thus, the virus spreads more rapidly in loose, spongy tissues, 



SOFT CEANORE OR GEANGROID. 109 

rich in blood and lymphatic vessels, than in textures that 
are poor in vascular supply. The submucous, subcutaneous, 
and interstitial connective tissues are very susceptible to the 
invasion of the chancre-poison. On the mucous membrane the 
chancroid ulcers are generally smaller than on the common 
integument. The chancrous poison never attacks serous and 
fibrous tissues, and very rarely those of a cartilaginous nature. 
Some parts of the skin afford the virus a more favorable soil 
than others. Larger chancrous ulcers will form more rapidly 
upon the inner surfaces of the thighs than upon the skin of 
the intercostal spaces or upper extremities, and upon the skin 
of the hypochondria quicker than upon the lateral surfaces of 
the thorax. Active local disturbances of the circulation of the 
skin — hyperemia, stasis, cedematous swelling, and especially a 
tendency to purulent infiltration — favor the destructive action 
of the chancrous poison. 

Action of Chancrous Virus and Development of the Soft Chancre. 

If chancrous matter in some way gets under the epidermis 
or epithelial cell-layer, a bright-red spot about the size of a 
lentil makes its appearance at the point of insertion in from 
twelve to twenty-four hours. By the next day this spot be- 
comes raised, and forms a kernel surrounded by a red areola. 
On the third day the kernel is transformed into a pustule, 
the areola spreads in extent corresponding to the growth of 
the pustule, and the skin within this areola is hard to the feel. 
It is sensitive and painful when pressed upon with the finger. 
On the fifth or sixth day the pustule collapses and dries up, 
forming a crust, and the red areola becomes smaller. On re- 
moving the crust, a circular, deep, or shallow ulcer, with sharp, 
undermined borders, is brought to view, whose bottom is cov- 
ered with a layer of grayish matter. 

The soft chancre develops on the mucous membrane in a 
similar manner, but here the pustules burst much earlier. If 
the chancrous matter penetrates into a sebaceous follicle, an 
acne or furuncle-like pustule will form, which also becomes 
transformed in from twelve to twenty-four hours into an ulcer. 
Excoriations and fissures become transformed by contact with 
chancrous matter directly into ulcers without the intervention 



110 PATHOLOGY AND TREATMENT OF SYPHILIS. 

of the pustular stage. The ulcers, however, are not round, but 
shaped like the excoriations or fissures, being mostly gaping 
and irregular. 

Multiple chancroids, originally circular, may coalesce and 
then form one chancroid irregular in shape and form. 

The chancrous ulcer enlarges proportionally in depth and 
circumference, but, when finally it begins to heal, the surface 
of the sore granulates, and a disposition to cicatrization is 
manifested. Sometimes the margins of the chancroids do not 
mark the limit of the action of the chancrous contagion. If a 
chancrous ulcer is cut through, the wound soon becomes an 
infected sore, the chancroid spreading and involving the entire 
incision. 

The chancrous ulcer emanates from the inflammatory altera- 
tion of the tissues, by which the affected structures become 
disorganized, passing through the conditions of fatty degenera- 
tion, softening or deliquescence (molecular disintegration), or 
the layer of tissue that is attacked by necrosis forms a diph- 
theritic membranous slough, which by excessive suppuration 
is subsequently detached and cast off. From the very begin- 
ning of the ulcerative process an active inflammatory plastic 
condition in the form of a slightly hard swelling becomes 
manifest. This proves microscopically to be papillary cell- 
infiltration, and causes the delimitation or the demarkation of 
the chancroid. 

Pathology of the Soft Chancre* 

In the soft chancre, as in every other kind of suppurating 
sore, a distinction may be made between the base and edges of 
the ulcer. The transition between the border and bottom may 
be very sharp. Ulcers whose bases are on a level with their 
edges are called superficial or flat chancroids : they resemble 
more or less lardaceous, yellowish excoriations. 

The base of the ulcer is uneven ; it has a jagged appear- 
ance, like worm-eaten wood. This uneven appearance is due 
to the fact that some portions of the tissue attacked in the 
ulcerative process resist the sloughing action more than others. 
The surface of the chancroid usually has a yellowish or 
lardaceous appearance produced by the fatty degeneration or 



SOFT CHANCRE OR CHANCROID. Ill 

molecular disintegration of the tissue-elements. Sometimes 
we find upon the surface of the sore a whitish-gray or greenish 
coating, if it contains any coloring-matter of the blood, simi- 
lar to the pseudo-membrane of diphtheritis of the fauces, and, 
like the latter, adhering tenaciously to the structure beneath. 
Such chancroids are called diphtheritic chancroids. They 
originate from intense infiltration of the connective tissue of the 
soft chancre with newly formed cells, which compress the cap- 
illaries of the cutis or mucous membrane and interfere with 
their nutrition. The diphtheritic layer is necrosed tissue in the 
form of a slough. This slough, when the sore is about to heal, 
is surrounded by a fissure — the so-called line of demarkation, 
which bleeds slightly, and is a result of the inflammatory re- 
action that has taken place in the outskirts of the dead material. 
The matter that forms from this inflammation accumulates 
between the sound tissue and the slough, and finally is thrown 
off. A diphtheritic chancroid generally causes greater de- 
struction of tissues. 

In many cases the base of the ulcer exists only for a very 
brief time, as in a soft chancre that perforates the frsenum or 
labia minora. Those parts which before the perforation formed 
the borders of the chancroid, afterward constitute its base. 

The base of the sore furnishes a secretion which consists 
partly of molecular matter, fatty degenerated tissue-detritus, 
and partly of pus-corpuscles in which generally some blood- 
globules are mixed. In places provided with numerous seba- 
ceous glands, the discharge will become mixed with rancid 
sebum, and acquire a most offensive odor, as in chancroids of 
the fossa coronaria. 

The anatomical process of healing is as follows : Deep in 
the tissues on which the chancroid is located a marked degree 
of development of the vessels takes place. These markedly 
vascular tissues are the germinating soil of granulations or mi- 
nute warts. These granulations may develop sparingly or in 
large numbers. Those which sprout in a normal manner form 
a velvety covering which is gradually transformed into cica- 
tricial tissue. In some cases the granulations proliferate so 
abundantly that the bottom of the sore rises above its edges 
(ulcus elevatum, fungosum, frambcesoides). 



112 PATHOLOGY AND TREATMENT OF SYPHILIS. 

The margins of the chancroid, in most cases, are thickened 
and swollen, because the papillae of the cutis involved are infil- 
trated with cells. The cells that have accumulated here, how- 
ever, degenerate as rapidly as those at the bottom of the sore ; 
hence also is seen the markedly dentated and undermined con- 
dition. When healing begins, the margins of the ulcer become 
adherent to the base by the growth of granulations, and then 
they become level with it. As a result of the stimulated en- 
largement of the cutis-papillae, a marked proliferation of the 
epidermis begins, which goes on toward the center of the ul- 
cer. Cicatrization of the chancrous ulcer will progress rapidly 
or slowly, according to the character of its edges. The less 
they are undermined, the smoother and flatter they are, the 
sooner may they be expected to cicatrize. Hyperemia and 
anaemia of the borders delay cicatrization. If the granulations 
under the edges of the ulcer sprout up too profusely, the mar- 
gins will become raised up and everted to such a degree as to 
form a wall around it. From excessive plasticity of the cellu- 
lar infiltration, this wall may become callous, so that the chan- 
croid ulcer acquires a hard ring around it (annular chancrous 
ulcer). Outwardly, the borders of the ulcer, so long as the 
destructive process goes on, are surrounded by a red hyperae- 
mic zone. "With the subsidence of this hyperemia, the de- 
structive process also subsides, and then the granulations begin 
to grow beneath the undermined margins. The acute zone 
abuts against apparently normal tissue — we say apparently nor- 
mal, because it is impossible to know how extensively the tis- 
sues around a soft chancre are morbidly altered by the ulcer- 
ative process. 

Course, Duration, and Cicatrization of the Soft Chancre. 

The destructive process in a soft chancre varies consider- 
ably as regards duration. In one case its progress is rapid, in 
another it is very slow. In one case the ulcer barely attains 
the size of a lentil, in another it becomes remarkably large. 
Now, the superficial surface of the papillary layer is barely 
destroyed (flat chancroid) ; and again not only the entire thick- 
ness of the cutis is perforated, but even the subcutaneous and 
submucous tissue is involved in the destructive process, where- 



SOFT CHANCRE OR CHANCROID. 113 

by sometimes entire organs, such as the glans, urethra, or labia, 
are destroyed. The tendency to gangrenous suppuration is not 
due to any specially specific infectious character of the dis- 
charge, but to a peculiar idiosyncrasy of the individual affected, 
although it can not be denied that in scrofulous and tubercu- 
lous persons, and those suffering from hunger and want, a soft 
chancre, as a rule, will grow to larger proportions than in 
healthy individuals. The depth to which the virus of a soft 
chancre, by infecting, may penetrate into the tissues, and the 
pus contained in the discharge from an infecting chancroid, 
seem to exercise greater influence upon the destructive pro- 
cess than the condition of the patient. But, in addition to the 
habits of the individual, local and external influences must be 
taken into consideration. The pus that is allowed to remain 
too long a time upon the surface of the chancroid not only acts 
as an irritant and is destructive to the granulations, but it also 
infects the parts in its vicinity. Arterial and venous haemor- 
rhage at the site of the sore favors the tendency to further ul- 
ceration. Mechanical injury of the sore, such as tearing and 
rubbing, chemical irritation from improper remedies, soiling 
with physiological secretions and pathological excretions, exer- 
cise similar unfavorable influences. 

In those cases in which none of these injurious influences 
obtain, the destructive process generally lasts from four to five 
weeks, and cicatrization requires about fourteen days more. 
The infectious property of the treated or untreated chancroid 
diminishes gradually as the granulations form on its periphery. 
The cicatrix alone does not fill up the space formed by the loss 
of substance ; the ulcer diminishes in addition through the re- 
traction of the skin. The shallower the ulcer, the less marked 
will the scar be. For a time the fresh scar is hypersemic, discol- 
ored, and slightly resistant ; after a while, however, it becomes 
pale and supple. The scar of a soft chancre, as a rule, does 
not break open again. 

Varieties of Soft Chancre. 

An erethistic and an atonic chancroid are distinguished ac- 
cording to the degree of the inflammatory irritation of the 
tissue involved in the suppuration. In the former there is a 
8 



114 PATHOLOGY AND TREATMENT OF SYPHILIS. 

marked inflammatory condition of the surrounding parts ; in 
the latter, the inflammatory reaction is absent, the discharge is 
slight and thin, the granulations grow very slowly, are dry, 
granular, and bleed easily. 

If a more intense degree of inflammatory phenomena ap- 
pear in the vicinity of a soft chancre of the skin, an erysipela- 
tous swelling will ensue. However, intense inflammation may 
give rise to stasis, by which not only the parts involved in the 
ulcerative process become necrosed, but also the parts adjacent. 
These varieties are called gangrenous chancroids, and this des- 
ignation is especially applicable to those with black sloughs, in 
contradistinction to those that are covered with a yellowish- 
white pseudo-membranous diphtheritic coating (called by Wal- 
lace ulcers with white gangrenous sloughs). 

If molecular necrosis comes on with unusual intensity, and 
if it progresses with such rapidity as to destroy a comparatively 
large section of tissues in a few hours, we have to deal with 
a variety of soft chancre that has long been known as the cor- 
roding or phagedenic chancroid. But even in this kind several 
varieties are recognized, such as the phagedeno-diphtheritic, the 
simple phagedenic, and the serpigino-phagedenic chancroids. 
The first occurs when one of the layers of sloughed tissue forms 
a lardaceous pseudo-membrane that adheres firmly to the sur- 
face of the ulcer. Phagedenic sores are called simple when 
they spread uniformly in every direction, and the serpiginous 
forms are those which, while spreading in one direction, form 
granulations in another. In regard to the serpiginous-pha- 
gedenic chancroid, we again distinguish a false and a true ser- 
piginous variety. The first kind spreads only downward 
toward the depending parts of the organ affected, and is due 
to a want of cleanliness ; the second generally extends upward. 
The false serpiginous form really depends upon repeated auto- 
inoculation. In these cases the initial chancroid is always 
situated at the highest point, while the newly formed sores 
occur at the lower and depending points. This kind of appar- 
ently serpiginous soft chancre is generally seen in the fossa 
corona gland is and on the inner surfaces of the labia majora. 

The simple phagedenic chancroid occurs far more fre- 
quently than the serpiginous variety. 



SOFT CHANCRE OR CHANCROID. 115 

Phagedena is apparently entirely due to the condition of 
the system, for these forms of soft chancre are found especially 
in weak and depraved individuals. The mode of life of these 
individuals is another very frequent cause. The abuse of spir- 
ituous liquors is an especially potent factor which seems to 
favor the production of the phagedenic condition; hence 
Ricord assumed the existence of an ulcus oniophagedsenicum. 
Active mercurial treatment, coexisting scrofula, tuberculosis, 
or anaemia — in short, all the influences which tend to under- 
mine the system, particularly favor the production of the pha- 
gedenic condition. The long duration of the soft chancre, and 
the equally long persistence of the infecting property of its 
secretion, are marked peculiarities of this form of the disease. 

Site of the Soft Chancre. 

A chancroid may occur on any part of the human integu- 
ment and mucous membrane that can be reached by contact. 
However, since most soft chancres are acquired through sexual 
intercourse, it is easy to comprehend why the majority of them 
must occur upon the genital organs of both sexes. But there 
are also other places of the human body upon which chancroids 
are often met with, though not, however, as often as on the 
genital organs. Thus, injuries on the fingers of physicians and 
midwives constitute points of insertion of the chancrous virus. 
Wet-nurses affected with chancres on the genital organs will 
carry the infecting poison to the moist nipples if they rub the 
latter with their fingers which have been soiled with the dis- 
charge from the sore. In those given to the practice of 
sodomy, the soft chancre may form upon the lips, the tongue, 
mucous membrane of the rectum, etc. Numerous cases have 
convinced us that the statement which Eicord made long ago, 
to the effect that the head was proof against the soft chancre, 
is incorrect. Chancroids discharging profusely are apt in un- 
cleanly persons to produce, by auto-inoculation, multiple soft 
chancres. The experiments of syphilization have shown that 
hundreds of soft chancres may be produced in the same person. 

Any part of the integument of the penis from the free 
border of the prepuce to the mons veneris may afford a site 
for a soft chancre. The prepuce, however, is the part that is 



116 PATHOLOGY AND TREATMENT OF SYPHILIS. 

most frequently attacked, especially its anterior or free margin, 
its inner surface, the frsenum, the corona glandis, and less fre- 
quently the external meatus of the urethra ; but the scrotum is 
also occasionally the site of the soft chancre. 

. In the female the soft chancre is most frequently met with 
upon the labia niajora and minora, on the posterior vaginal 
commissure, and at the vulvar orifice, more rarely in the vagina 
and vaginal portion of the uterus. In unclean women, suffer- 
ing from soft chancres on the genital organs with profuse dis- 
charge, the matter coming in contact with excoriations around 
the anus will convert the latter into chancroids. 

The peculiarity, situation, and functional activity of the 
tissues, spoken of here, on which a soft chancre is apt to occur, 
exercise a greater or lesser degree of influence upon the devel- 
opment and course of the chancrous sore. 

Chancroids of the prepuce are very obstinate and difficult 
to cure, because the foreskin is frequently stretched in its 
movements over the penis, and the sore is prevented from heal- 
ing. In addition, it is apt to become soiled by the urine and 
the glandular sebaceous secretion. In congenital phimosis, or 
that acquired from temporary swelling of the prepuce, the 
preputial chancroid is even more frequently and more mark- 
edly exposed to mechanical and chemical injuries. Soft 
chancres of the mucous membrane of the prepuce usually be- 
come complicated with catarrh of the glans and of the pre- 
puce. Preputial chancroids often give rise to chancroids on 
the glans through infection by contact. In cases of marked 
contraction of the preputial opening, such a degree of disturb- 
ance of the circulation occurs as to produce gangrene of the 
foreskin and glans. Impending gangrene of the prepuce mani- 
fests itself in the following manner : The patient complains of 
severe pain in the affected part, the prepuce swells enormously, 
becomes red, has a high temperature, and a foul-smelling, 
purulent discharge flows from the preputial orifice. If the 
impending dangerous condition is not quickly subjugated by 
appropriate treatment one or more blue spots appear on the 
external surface of the prepuce. In a few hours they become 
transformed into a black gangrenous slough, which after a 
while is cast off. The gangrene either limits itself to one or 






SOFT CHANCRE OR CHANCROID. 117 

several points on the foreskin, an opening forms, through 
which the glans penis, till now imprisoned in the preputial 
pouch, is laid bare ; or the gangrene sloughs away the entire 
prepuce, attacks the glans itself, and destroys the greater 
part of it. If the arteria dorsalis penis is corroded by the 
sloughing process, dangerous haemorrhage may supervene, as 
ligature of the vessel involved in this gangrenous process 
almost always proves futile. 

Chancroids of the frcenum are situated either on one or 
both sides, or on the margin of this membrane. In the two 
former conditions, perforation almost always takes place. The 
perforated spot, as a rule, cicatrizes very slowly and very rarely. 
In most cases, the bridge of the skin that has remained intact 
breaks down, often causing serious haemorrhage from the arte- 
rial twigs that run along the free margin of the fraenum, that 
is difficult to arrest. Usually, the fraenum is entirely destroyed, 
and an ulcer results, that extends from the point of attachment 
of the fraenum, near the fossa coronaria, to the urethral orifice, 
and from this point it may even encroach upon and attack the 
mucous membrane of the urethra. Soft chancres at the mar- 
gin of the fraenum spread very quickly in the loose connective 
tissue existing between the two lamellae of that part ; may 
•lay bare the urethra, and even perforate it. They are the 
most frequent cause of swelling of the inguinal lymphatic 
glands. 

A chancroid may occur on any part of the glans penis. In 
coexisting contraction of the preputial orifice, chancrous impres- 
sions will result on the mucous layer of the prepuce ; and when 
cicatrization ensues, the foreskin may become firmly united to- 
the glans. In the shallow pits or crypts which are found on 
the dorsum of the glans penis, and which are the rudiments of 
the sebaceous follicles that exist here in the embryonal state, 
soft chancres assume the shape of follicular ulcers. Superficial 
chancroids cicatrize very quickly. If the chancrous destruc- 
tive process penetrates into the corpus cavernosum glandis, and 
assumes a phagedenic character, it may destroy such a large 
portion of the glans, owing to the spongy and vascular nature 
of the tissues, as to result in actual mutilation of the organ. 
In consequence of the exceedingly thin layer of the subcuta- 



118 PATHOLOGY AND TREATMENT OF SYPHILIS. 

neons connective tissue, the cicatrization of such chancroids 
progresses very slowly. 

Chancroids of the external meatus urinarius are situated 
either npon one or both lips, and thence may spread into the 
nrethra. After cicatrization has taken place, the ostium ex- 
ternum urethra (the orifice) acquires a funnel shape. We have 
never, either during the life of the patient or at the autopsy, 
met with chancroids that have originated within the urethra 
behind the fossa navicularis. 

The numerous sebaceous glands existing in the fossa coro- 
naria glandis become diseased from the action of the chancrous 
poison, and assume the form of acne-like tubercles. These are 
transformed into ulcers of the size of a millet-seed, and may 
surround the entire fossa coronaria, like a string of pearls. Fi- 
nally, even the sound parts between the ulcers are destroyed, 
and they then coalesce into one ulcerating groove. If such a 
follicular ulcer spreads to and attacks the subcutaneous con- 
nective tissue of the dorsum of the penis, a fistulous track from 
the fossa coronaria to the mons veneris will result. 

In the female, soft chancres at the posterior commissure 
readily become phagedenic or gangrenous, because the physio- 
logical secretion and pathological excretions produced in the 
uterus and vagina, as well as the urine, are liable to accumulate 
there. As a rule, chancroids on the os uteri are not disposed 
to attack the deeper tissues ; nevertheless, marked loss of sub- 
stance and serious haemorrhage have been observed. 

Differential Diagnosis of the Soft Chancre. 

The soft chancre may be mistaken for herpes on the geni- 
tal organs, for an ordinary sore, the initial lesion of syphilis, 
and the cancer-ulcer. 

It is only possible to mistake a chancroid for herpes on the 
genital organs during its initial pustular stage. The distinctive 
features of the two are as follows : The herpes vesicles gener- 
ally appear in groups ; soft chancres commonly only one at a 
time. The former are barely as big as a pin's head ; the lat- 
ter, as a rule, are larger. A group of herpes vesicles has one 
common, erythematous red base ; each soft chancre is sur- 
rounded by a marked, slightly infiltrated red zone that is -per- 



SOFT CHANCRE OR CHANCROID. 119 

ceptible to the touch. The herpes vesicles may exist for sev- 
eral days before bursting ; the chancrous pustule breaks in ten 
or twelve hours after it has made its appearance. The ruptured 
herpes vesicles dry up, without undergoing ulceration, forming 
a thin orbicular scale corresponding to the old vesicle. After 
the bursting of the chancre-pustule, a loss of substance ensues 
that has a tendency to spread. A chancroid always leaves a 
depressed cicatrix after it which lasts for a variable period ; 
herpes leave cicatrices that are visible but a few days, and 
indistinctly depressed or discolored. Herpes of the genital 
organs, in most cases, is an habitual disease, which may come 
on without or long after sexual intercourse. The pustule of 
a soft chancre begins about twenty-four hours after a suspi- 
cious cohabitation or infection with chancrous discharge. 

Lacerations and excoriations originating after sexual inter- 
course may, from neglect of cleanliness or improper treatment, 
assume an ulcerating character, and then be mistaken for 
chancrous ulcers. The course of these sores, or inoculation 
performed with their secretion, will quickly dispel all doubt. 
Ordinary ulcers heal readily enough when kept clean and 
properly managed ; and a pustule produced by inoculation 
with their secretion soon dries up and heals. 

The most important point in reference to the prognosis 
is the differential diagnosis between a soft chancre and the 
initial syphilitic ulcer. The syphilitic initial lesion rests 
upon a marked, sharply defined cellular infiltration, which 
bears no relation to the slight ulceration and suppuration. 
The soft chancrous ulcer is seated upon a base that has become 
somewhat resistant in consequence of the reactive inliammatory 
process. The initial lesion of syphilis, when grasped between 
the thumb and index-finger, shows the consistence, resistance, 
and elasticity of fibroids and enchondromata. The soft chan- 
cre, pinched up in a fold between the thumb and forefinger, 
will have at the most an oedematous or doughy feeling. Only 
tardy or repeatedly cauterized soft chancres, situated in the 
sulcus coronse glandis and genito-crural fold, sometimes occa- 
sion a temporary indurated inflammation of the connective 
tissue that may be mistaken for the hard consistence and elas- 
tic resistance characteristic of the syphilitic tissue induration. 



120 PATHOLOGY AND TREATMENT OF SYPHILIS. 

In the soft chancre the inflammatory induration disappears 
spontaneously in a comparatively short time, and is not at- 
tended by hard, indolent swelling of the lymphatics. The 
syphilitic infecting ulcer is distinguished by its hyperplastic 
adventitious structure; the soft chancre is pre-eminently a 
destructive process. The syphilitic primary lesion, as a rule, 
develops very slowly, and, after a protracted incubation period, 
the soft chancre appears within a few hours or days after in- 
tercourse. The ulcerating process in the initial lesion of syphi- 
lis attacks layer after layer of the indurated deposit, the 
necrotic process proceeding from without inward, owing to 
the intense cellular infiltration. The capillaries in the part 
then become occluded, and the uppermost layer of the neo- 
plastic formation dies for want of a blood-supply ; conse- 
quently, the discharge from this lesion is very slight. The 
ulcerative process of the soft chancre proceeds rapidly, consti- 
tuting a purulent dissolution of the tissues; hence the dis- 
charge is quite profuse. Primary syphilitic lesions resembling 
erosions occasionally cicatrize so rapidly that they entirely es- 
cape observation ; in the soft chancre such rapid cicatrizations 
never occur. The scar of a syphilitic sore is hard to the feel, 
because the hyperplastic deposit remains for a long time ; the 
scar of a soft chancre never becomes hard. The cicatrix of a 
primary syphilitic chancre often breaks open again ; that of a 
soft chancre hardly ever. The cellular infiltration of a syphi- 
litic primary lesion, after being absorbed, may reappear after 
a long while without the recurrence of infection (repullulation 
of the syphilitic initial sclerosis) ; in the soft chancre such a 
condition never takes place. In the cicatrized syphilitic Hun- 
terian induration, deep depressions originate, as a result of 
atrophy ; in the scar of the local venereal chancroid, such de- 
pressions are never observed. Indolent swelling of the lym- 
phatic glands and diseased condition of the lymphatic vessels, 
as a rule, are the accompaniments of the initial lesion of syphi- 
lis, and seldom undergo suppuration ; as a result of the soft 
chancre, however, the lymphatic vessels and glands are quite 
often affected (in twenty out of one hundred cases), and gener- 
ally they undergo suppuration. Although we have enumerated 
here certain peculiar features and differences of form, and laid 



SOFT CHANCRE OR CHANCROID. 121 

stress upon the essential distinctive symptoms for the purpose 
of specializing the characteristics of the soft chancre and the 
primary lesion of syphilis, still, to be candid, we must admit 
that here, as in other instances of natural phenomena, excep- 
tions and peculiarities of condition sometimes occur. The in- 
itial sclerosis may be indistinct, or the indolent swelling of the 
glands may be absent altogether, and yet a chancre may be 
followed by syphilitic manifestations. 

It is much easier to mistake a soft chancre for an epithe- 
lial cancer, as the latter very often occurs on the prepuce, glans 
penis, and scrotum, and is frequently attended by suppuration 
of the adjacent lymphatic glands. Epithelial cancer generally 
occurs in the form of a papillary, wart-like growth, which soon 
becomes necrotic, and gradually attacks the deeper structures 
whereby the textures upon which it is situated soon become 
eroded (ulcus rodens). Cancerous ulceration progresses more 
by death of the upper cell-strata of the deficiently nourished 
skin than by suppuration. Hence, we usually find here flat 
erosions whose upper surface is tolerably dry. Xow, while 
the base of the ulcer purifies itself, new papillary growths 
originate on its borders, by the death of which the destruction 
of the tissues spreads farther and farther. From these papil- 
lary growths, comedos or sebaceous plugs, consisting of flat or 
cylindrical epithelial cells, may be pressed out, through the 
proliferation of which the skin and subcutaneous tissue are de- 
stroyed (Klebs). 

Prognosis and Treatment of the Soft Chancre. 

The prognosis of a soft venereal ulcer depends (1) upon its 
location, and (2) upon the state of the inguinal lymphadenitis. 

In regard to its location, some kind of chancroids, especially 
phagedenic and gangrenous forms, cause greater destruction 
and mutilation of the parts than others. Arterial haemorrhages 
may take place from erosion of the arteria dorsalis penis and of 
the arterial branches in the frgenum, and cause considerable 
trouble. 

In regard to the occurrence of inflammation of the inguinal 
lymphatic glands, experience has shown that in twenty out of 
one hundred cases of soft chancres suppurating adenitis of the 



122 PATHOLOGY AND TREATMENT OF SYPHILIS. 

groin takes place, that it occurs more frequently in the male 
than in the female — in the male, especially when the chancroid 
is situated on the frsenum and on the internal surface of the 
prepuce ; and in the female, in consequence of the chancroids 
occurring in the lacunae on both sides of the urethra. In re- 
gard to the affection of the inguinal lymphatic glands, small, 
rapidly cicatrizing chancroids do not admit of a prognosis that 
is more favorable than other varieties. 

The treatment of the soft chancre is either prophylactic or 
abortive, curative or methodical. 

Prophylactic Treatment. 

Besides the condom we have no remedy or agent that will 
protect one against receiving the virus of a chancroid, or will 
render it harmless to the system after it is brought in contact 
with some part of the living cutis or mucous membrane. Even 
the highly praised lotions which have been recommended to 
be used immediately after exposure to a suspicious intercourse, 
prove entirely useless in very many cases. By thoroughly 
washing the genital organs immediately after cohabitation, we 
may succeed in removing any infecting substance that may 
have been lodged there, and in this w T ay we may probably, but 
not positively, prevent the virus from taking root and exer- 
cising its effects. 

Abortive Treatment. 

Kicord succeeded in preventing the further development 
of the chancroid pustules which he had produced by inocula- 
tion by timely cauterization, thus bringing about cicatrization 
and healing, and thereby obviating the extension of the disease 
to the adjacent lymphatic vessels and glands. It was found, in 
the course of experience, that the pustules of soft chancres, 
and of erosions contaminated with the pus of a soft chancre, 
if thoroughly destroyed within seventy-two to ninety-six hours 
after infection had taken place, will be arrested in their further 
development. But if a longer time than that just mentioned 
has elapsed since exposure to the action of the virus, or if an 
adjacent gland is already attacked by inflammation and swell- 
ing, cauterization of the infected spot will be entirely useless. 



SOFT CHANCRE OR CHANCROID. 123 

To be effectual, the caustics must also destroy sufficient adja- 
cent sound tissue. For this purpose a great variety of caustics 
has been recommended. Nitrate of silver, caustic potassa, 
pure or combined with unslaked lime (Yienna paste), or Fil- 
hos's caustic (equal parts of caustic potash and unslaked lime 
cast in molds like a pencil), chloride of zinc, fluid, or combined 
with some simple substance in powder (pulv. secalis or pulv. 
rad. liq.), as Canquoin's paste, or in the form of pencils recom- 
mended by Kobner (zincum mur., gram. 1 [grs. xvj], kali 
nitric, 0*20 to 040 [grs. iij to vj], melted and quickly wrapped 
in tin-foil and preserved in glass tubes or bottles), butyr. antimo- 
nii, chloride of mercury, 0*50 to 5*00 or 10*00 water [grs. vij 
to 3iv or 3 ij, 3ij], sulphuric and nitric acid, and the actual or 
galvanic cautery. In the abortive treatment we only employ 
nitrate of silver in stick or a concentrated solution (a saturated 
solution is eleven parts of the nitrate to ten of water). This 
solution destroys the tissues that are impregnated with the 
chancrous virus more effectually than the solid stick of nitrate 
of silver. ~No wet compresses should be applied to the cau- 
terized spot ; it should be kept dry, for the purpose of keep- 
ing the eschar produced by the caustic from dissolving and 
flowing over adjacent parts. After the slough produced by 
the caustic has been cast off, some astringent preparation may 
be applied by means of cotton-wool compresses. 

The part on which the virus of the chancroid has been 
lodged may also be excised. But, in the first place, the oper- 
ation can not be carried out in every case ; and, secondly, it is 
not always effectual, because we are not sure when the chan- 
crous poison ceases to be active, nor to what extent the incision 
should be made around the affected spot. 

Curative or Methodical Treatment. 

If the abortive treatment has failed, if more than five days 
have elapsed since infection took place, if one or more of the 
adjacent lymphatic glands is already irritated or inflamed, 
the methodical or curative treatment should be instituted. It 
has to fulfill the following objects : To prevent the extension 
of the ulcer in breadth and depth ; to protect adjacent parts 
against auto-inoculation ; to promote the cicatrization of the 



124 PATHOLOGY AND TREATMENT OF SYPHILIS. 

ulcer ; and to check the swelling and suppuration of the neigh- 
boring lymphatic glands. These objects are attained parti y by 
appropriate regimen and conduct on the part of the patient, 
and partly by proper local treatment. 

The patient should avoid all active exercise, such as fenc- 
ing, riding, dancing, etc. If there are already signs of active 
inflammation in the affected parts, especially if any of the 
glands of the vicinity are tender or painful, the patient will do 
well to go to bed. His diet should be light, spirituous or other 
stimulating drinks should be interdicted, or at the most al- 
lowed in moderate quantities, and only to those accustomed to 
their use. 

The chief indication in local treatment consists in keeping 
the affected parts scrupulously clean, which is best accomplished 
by the speedy removal of the discharge from the sore, by pro- 
tecting it from contamination with physiological secretion and 
pathological excretion. This is best achieved by repeatedly 
washing the diseased part (topical baths), and by the applica- 
tion of iodoform. 

Iodoform in powder should be dusted upon the ulcer, and 
a bit of absorbent cotton dipped in a two-per-cent solution of 
carbolic acid in water, and squeezed out well, is then applied. 
To prevent the dressing from becoming too dry, it should be 
covered with a piece of gutta-percha, and the whole secured by 
a bandage. This dressing must be renewed two or three times 
a day, according to the quantity of the discharge. If the penis 
is markedly swollen, the patient should be confined to bed, and 
the organ kept upon the abdomen. In the majority of cases 
the ulcer becomes clean in a short time under this treatment. 
If granulations have begun to form, the iodoform dressing may 
still be used, or only a carbolic-acid solution ; or, still better, 
empl. hydrarg. may now be substituted for either, especially if 
the patient desires to leave the bed. Exuberant granulations 
should be repressed by touching them from time to time with 
the solid nitrate of silver, which will also expedite the cicatri- 
zation of the sore. 

If under this treatment the ulcer remains stationary, and, 
still more, if it enlarges markedly and rapidly, which is a most 
unusual circumstance, or assumes a diphtheritic character; if 



SOFT CHANCRE OR CHANCROID. 125 

the discharge is profuse, and granulations are slow to appear, 
one of the following preparations should be resorted to : 

5 Cupri sulphurici, 0*50 [grs. viij] ; 

Ung. elemi., 50-00 [ § iss„ 3 v]. M. Ft. ung. 

A bit of this salve, of the size of a lentil, is smeared upon 
a small strip of muslin and applied to the ulcer two or three 
times a day, after bathing the organ in tepid warm water. In 
diphtheritic or phagedenic chancroids, that do not heal under 
the application of iodoform, an emulsion of camphor, caustic 
potash, or nitrate of silver, with balsam of Peru may be em- 
ployed — like the f olio wing : 

5 Camphora, 5*00 [3 iv]; 
Mucil. g. arab. ; 
Aqua destil., aa 50-00 [ § j, 3 vj]. M. 

I£ Kali caustic, 0*10 [grs. jss.] ; 

Aqua destil., 50*00 [ gj, 3 vj. M. 

Yp Argent, nitrici, 0*10 [grs. jss.]; 

Balsam. Peruvianas, 30-00 [ § j]. H. Ft. ung. 

In ulcus luxurians or elevatum [fungous], a strong astrin> 
gent, or mild caustic, should be resorted to. 

In dry granular ulcers, with callous edges and scanty secre- 
tion, lint moistened with glycerine, or the empl. hydrarg., should 
be applied. 

In phagedenic soft chancres general treatment will be neces- 
sary in addition to the use of local remedies, because the 
phagedena in all probability is due to scrofula, tuberculosis, 
anaemia, scorbutus, habitual digestive disturbances, etc. It 
will, therefore, be necessary to resort to the remedies most 
effectual in the treatment of these various diseases. Mercury 
is to be strictly avoided in the treatment of phagedena. We 
have rarely succeeded in arresting the progress of phagedsena 
by caustics, but we are able to recall numerous instances in 
which we obtained the happiest results from the use of acetate 
of lead or citrate of iron, combined with tincture of opium. 
In simple phagedenic chancre we therefore recommend — 

I? Ext. saturni, 2*00 [grs. xxxij]; 
Aqua destil., 100-00 [ § vjss.J ; 
Tr. opii eoinp., 5*00 [3 iv]. M. 



126 PATHOLOGY AND TREATMENT OF SYPHILIS. 

^ Citr. ferri, 1-00 [grs. xvj] ; 
Aqua destil., 100-00 [ | vjss.] ; 
Tr. opii couip., 2'00 [grs. xxxij]. M. 

One of the most reliable remedies, besides iodoform, we 
found to be a mixture of chloroform and glycerine, one part to 
six. The tartrate of iron, one part to six, is recommended by 
Eicord as a specific against phagedena. 

Excision of the phagedenic chancroid, at the most, can 
only be recommended when it is situated upon the frsenum, 
the free margin of the prepuce, and at the edges of the labia 
majora or minora. 

In the treatment of gangrenous chancroid it will be neces- 
sary first of all to ascertain the causes that brought about the 
gangrenous condition. These are apt to be : Grave stasis, a 
profuse flow of blood in the phlegmonously inflamed part, and 
mechanical obstruction to the return of the blood, when the 
supply is excessive ; this may occur as the result of pressure, 
strangulation, phimosis, and paraphimosis. In any event, rest 
in bed should be recommended, ice-cold applications made, and 
in men the penis should be kept upon the abdomen, for the 
purpose of diminishing the supply of blood to the part, and ac- 
celerating its return. In congenital or phlegmonous phimosis, 
in which the retraction and extension of the prepuce for the 
purpose of cleansing the parts cause intense pain and irritate 
them, besides rendering the chancroids almost inaccessible and 
preventing the local application of remedies, it will be more 
advantageous to split the prepuce, or to perform circumcision. 
Arterial haemorrhage caused by gangrene must be arrested by 
the application of the ligature, compression, or transfixion. If 
these methods fail, chloride [or persulphate] of iron, or the 
actual cautery, should be used. In all cases of phimosis, where 
there is no danger of gangrene, and the patients decline to be 
circumcised, injections of solution of nitrate of silver should 
be made into the preputial pouch four or ^ve times a day, and 
retained there for a few moments. Or, after injecting water 
into the pouch, and then drying it as well as possible, the glans 
should be cauterized by inserting a solid piece of nitrate of 
silver between it and the prepuce, and rapidly rubbing it all 
over. After the injection or cauterization three or four pieces 



SOFT CHANCRE OR CHANCROID. 127 

of compressed sponge, each about two and a half centimetres 
long and two millimetres thick, according to the distensibility 
of the prepuce, should be inserted between the prepuce and 
glans, and renewed several times daily. In this manner the 
preputial sac is sometimes dilated to such a degree that after 
the cicatrization of the chancrous ulcers it can be retracted 
with the utmost facility. We do not recommend this method 
of treatment very strongly, preferring early circumcision for 
the relief of this complication. 

In cases complicated with paraphimosis, circumcision will 
almost always be required. If the patient absolutely refuses 
to have it done, the penis is to be laid upon the abdomen, cold- 
water dressings applied to it, and attempts made to apply ap- 
propriate remedies, by means of camel' s-h air brushes, between 
the folds of the constricting prepuce. If dangerous stasis, in 
consequence of the constriction, takes place in the prepuce or 
glans penis, the operation will have to be performed without 
further delay. 

In chancroids of the ostium externum urethrse, it will be 
the duty of the physician to prevent contraction of the ure- 
thral orifice during cicatrization. This is best effected by in- 
serting into the meatus plugs of charpie, or some other mate- 
rial, dipped in some resinous or other kind of ointment, or 
pieces of bougie, which should be secured to the penis by 
tapes and adhesive plaster, and which the patient may remove 
before micturition. Iodoform, made into sticks with some 
solidifying substance, is also very well adapted for this pur- 
pose. 

Chancrous ulcers at the anus require prolonged washing 
and sitz-baths after each stool. 

In perforating chancroid of the frcenum, pledgets of lint, 
smeared with ointment of sulphate of copper, should be care- 
fully introduced, several times daily, into the hole, or the per- 
foration touched with the solid nitrate of silver. If the swell- 
ing is very great and the pain intense, dividing the bridge 
is the most appropriate procedure. Ricord has suggested an 
excellent measure for this purpose, by which the bleeding is 
avoided and the further progress of the ulceration restrained. 
Two waxed ligatures are passed through the opening, and are 



128 PATHOLOGY AND TREATMENT OF SYPHILIS. 

then separately tied upon the bridge of the fraenum, one thread 
after the other. The part between the two tied ligatures 
breaks down in a few hours or days, or it may be cut through 
at once, without fear of causing haemorrhage. 

In the female, scrupulous cleanliness must be enjoined, and 
carried out with even greater rigor than in the male, because 
the sebaceous and mucous follicles of the genital organs, ow- 
ing to the presence of chancroids, are stimulated to hyper- 
secretion. The discharge from the chancroid sores, and the 
secretion from the genital organs, flowing over the adjoining 
parts, will cause erosions to form at the genito-crural fold, on 
the perinseum, and around the anus, which soon develop into 
chancroids. Menstrual blood, the lochia, and vaginal catarrh, 
delay for a long time the cure of a soft chancre, if it is situated 
upon the vulvo-vaginal mucous membrane, and especially on the 
posterior commissure. Care should therefore be taken to cure 
the existing catarrh as soon as possible, sitz-baths taken often, 
vaginal douches repeatedly resorted to, and the sore frequently 
and thoroughly cauterized with the solid crayon of silver. This 
method is all the more applicable in the female, because the 
chancroids, in the vast majority of cases, are situated upon the 
mucous membrane, and bear strong cauterizations better than 
those in the male, situated upon the common integument. Aside 
from this, the treatment differs in no respect from that of chan- 
croids in the male. Chancroids situated upon the upper part of 
the vagina or neck of the uterus must be cauterized through 
the speculum, with a long caustic holder. The parts that are 
likely to come in contact with a chancroid should be protect- 
ed, by inserting repeatedly between them pledgets of wad- 
ding, saturated with some disinfecting solution, to prevent auto- 
inoculation. 

Diseases of the Lymphatic Vessels and Glands (Lymphangioitis 
and Adenitis) in consequence of Soft Chancre. 

Daily experience has shown that the lymphatic glands, 
situated in the vicinity of a collection of pus or ichor, which, 
are produced idiopathically or by infection, furthermore those 
in the vicinity of inflammatory deposits of a malignant nature, 
very often become inflamed and swollen. In some cases they 



SOFT CHANCRE OR CHANCROID. 129 

undergo resolution, but in others terminate in suppuration. 
These forms of swelling of the lymphatic glands are due to the 
agency of the lymphatic vessels, the fluids originating from the 
irritative lesions, indeed even viable cells and particles of dead 
structures, being taken up by them and conveyed to and de- 
posited in the corresponding lymphatic glands. As a result of 
this condition only those glands become affected in which the 
diseased lymphatic vessels terminate, while the lymphatic ves- 
sels which run toward the primarily diseased spot undergo no 
perceptible morbid alteration. Occasionally, however, the mor- 
bid matter that has been absorbed also irritates the lymphatic 
vessels. 

In many cases there is found a swelling of the thickness of 
a cord under the skin, upon the dorsum of the penis, running 
from the local sore to the nearest lymphatic glands. This 
cord-like swelling is nothing more than a lymphatic duct, 
thickened by coagulation of lymph, as a result of absorption 
of diseased fluids from the original lesion. This thickening of 
the lymphatic vessel may be ushered in with marked inflam- 
matory phenomena, or without the least constitutional disturb- 
ance. Purulent urethral and preputial catarrh, erethistic ul- 
cers, soft chancres upon the external genital organs, generally 
give rise to painful inflammatory swelling of the lymphatic 
vessels. Initial syphilitic lesions likewise produce disease of 
the peripheral lymphatic vessels ; in the latter case, however, 
no inflammatory manifestations occur. 

The first form of disease of the lymphatic vessels is called 
inflammatory ; the second is spoken of as irritative. In both 
cases the affected lymphatic cord may be uniformly distended 
throughout its entire length, or knotty in one or more places. 
These lymphatic nodules are called bicbonuli, while the swell- 
ing of the lymphatic glands is called bubon, or bubo. If 
the patient is carefully and properly treated, the affected 
lymphatic duct will regain its normal thickness. In the con- 
trary event, and especially if the cause of the disease of the 
lymphatic vessel is a soft chancre, the inflamed nodules in the 
lymphatic duct will undergo suppuration. The integument 
covering the swelling of the lymphatic vessel ruptures, and a 
chancrous ulcer develops at this place. In swellings of the 
9 



130 PATHOLOGY AND TREATMENT OF SYPHILIS. 

lymphatic vessels, as a result of syphilitic initial lesions or of 
urethral catarrh, suppuration seldom occurs. 

The affections of the lymphatic vessels of the external gen- 
itals, that have been just described, occur most frequently in 
the male on the dorsum or sides of the penis, and along the 
frsenum. They are very seldom met with in the female, and 
then only on the labia majora. Disease of the lymphatic ves- 
sels which start from the preputial orifice may produce tem- 
porary phimosis. Lymphatic ducts that have undergone sup- 
puration will require a much longer time to get well than 
would be required for resolution of non-suppurating inflamma- 
tion. Affections of the lymphatic vessels and swellings of the 
lymphatic glands do not always have the same course and ter- 
mination. The swelling of the lymphatic vessels may become 
absorbed, while that of the glands goes on to suppuration, or 
vice versa. Swelling of the lymphatic glands may originate 
without coincident swelling of the afferent lymphatic vessels, 
in the same manner as an epididymitis may occur without 
thickening and inflammation of the spermatic duct. 

The morbid matter that has been transported to the glands 
does not always occasion inflammation in them ; sometimes it 
only causes an irritation. In the course of the complaint this 
irritation may develop into a painful inflammatory lesion, acute 
swelling of the glands, or it causes, without any increase of 
the temperature and without any pain, an hypertrophy of the 
glands through increase of the hyperplastic element, forming 
chronic or indolent glandular enlargement. The acute or 
chronic state of the glandular swelling, and its future destiny, 
depend first upon the character of the morbid matter trans- 
ported to the glands by the lymphatic vessels, and, secondly, 
upon the constitutional condition of the individual. If in- 
tercellular substance, pure, or gonorrheal pus, originating 
from excoriated places, is transported to a gland in a person 
in all other respects perfectly well, an acute glandular swell- 
ing will be produced, which will either terminate in reso- 
lution or suppuration, according to the behavior and constitu- 
tion of the patient. But if matter from a soft chancre in 
a state of acute inflammatory suppuration is conveyed to the 
gland, the latter will to a certainty undergo inflammation and 



SOFT CHAN GEE OR CHANCROID. 131 

suppuration. If the discharge or the detritus of an initial or 
secondary syphilitic ulcer is conveyed to the gland, an indolent 
glandular swelling mil result, which only undergoes suppura- 
tion when certain pre-existing conditions co-operate, or when a 
new irritation favoring suppuration is transported by addi- 
tional matter. Of all the lymphatic glands in the human 
body, the glands in both inguinal regions are the most fre- 
quently affected in the manner described. All glandular tu- 
mors are now called bubon, because formerly the Greeks called 
the inguinal glands bubones, or buboes (ftovftwves;). 

Physiologically considered, the glandular affection deline- 
ated above may be called resolution buboes. But, if the source 
of the absorbed fluid is taken into consideration, we might 
speak of common, gonorrheal, chancroid, and syphilitic buboes. 
Further, since absorption-buboes are always preceded by some 
morbid alteration, they may be designated as deuteropathic or 
secondary buboes. 

Protopathic or idiopathic buboes (bubons d'emblce of the 
French) are said to occur when the glandular hypertrophies 
were not preceded by any lesions of the adjacent skin or mu- 
cous membrane, and consequently did not originate by absorp. 
tion of noxious matter. Cazenave, Yidal de Cassis, and Diday 
are even of the opinion that chancroid and syphilitic virus are 
capable of causing disease of the lymphatic glands without 
previously establishing any purulent foci on the skin or mu- 
cous membrane. Yirchow maintains that all glandular hyper- 
trophies are preceded by a lesion of some kind, and where 
none is found he asserts that it has disappeared, as in the so- 
called idiopathic adenitis, while the enlargement remains. He 
says, moreover, that in tender, irritable lymphatic glands, such 
as are generally found in scrofulous persons, any lesion which 
in a robust person would be of no consequence whatever is 
liable to produce the most severe and obstinate glandular swell- 
ings. We can not, however, refrain from expressing our opin- 
ion that, in consequence of constitutional conditions, such as 
scrofula, leukaemia, or syphilis, lymphatic glandular enlarge- 
ment may originate without having been preceded by any le- 
sions of the adjacent parts. These kinds of glandular hyper- 
trophies are called constitutional buboes, or adenitis. 



132 PATHOLOGY AND TREATMENT OF SYPHILIS, 

Buboes originating as a Result of Soft Chancres. 

Swelling of the lymphatic glands, occurring in consequence 
of a soft chancre, generally soon undergoes suppuration. Ow- 
ing to their rapid development, these buboes are called acute 
buboes, and, assuming that the pernicious matter that was con- 
veyed to the glands was chancrous virus, virulent or chancroid 
buboes. However, even soft chancres may give rise to indolent 
disease of the glands. It is still a mooted point whether, in 
such cases, any chancroid pus has been absorbed, or whether 
other factors play a part. This form of indolent glandular 
swelling may, later on, after weeks or months have elapsed, 
assume an acute character, and in its subsequent course differ 
in no respect from those affections of the glands that are ush- 
ered in by acute symptoms. 

A virulent bubo usually originates in the first week after 
the appearance of the soft chancre ; sometimes, however, after 
the latter has completely cicatrized. This form of retarded 
adenitis indicates that the pernicious matter that has been ab- 
sorbed is being slowly transported to the glands. But if such 
a glandular swelling does not undergo suppuration, or if, in 
case it suppurates, the pus by inoculation in persons unaffected 
with syphilis occasions no ulcer, we may assume that the chan- 
crous sore, at the time the discharge was absorbed from it, no 
longer generated any virulent matter. 

It is highly probable that by the absorption of the chan- 
croid virus, at first, only one or a few glands are affected. The 
original size of the glandular swelling is barely as large as a 
pea. The swelling generally begins with severe pains, which 
are aggravated by the least pressure, and occasionally accom- 
panied by febrile movement. Gradually the territory beyond 
the affected gland becomes sensitive, the skin covering the 
glandular tumor also becoming tender. Even the movements 
of the limb on the same side as the glandular swelling cause in- 
tense pain. The skin over the swelling gradually increases in 
redness, and it is difficult to pinch it up in a fold — a proof that 
it and the subjacent connective tissue have already become 
united to the affected glands. In the course of the disease the 
capsule of the suppurating gland bursts, the surrounding con- 
nective tissue imbibes the virulent matter, terminating in a 






SOFT CHANCRE OR CHANCROID. 133 

purulent fusion of the entire mass. A virulent or chancroid 
bubo is therefore generally a complication of suppuration of 
the connective tissue and of the lymphatic glands. After the 
pus has formed, the febrile phenomena usually subside, and the 
pains on moving the corresponding limb are less severe. Grad- 
ually the swelling points, the skin over it becomes livid red at 
the highest point, the epidermis peels off, and, finally, the ab- 
scess breaks and pus escapes. 

Up to the point of rupture, adenitis originating from ab- 
sorption of chancrous pus is analogous in its development to 
those lymphatic swellings of the glands that are caused by or- 
dinary or gonorrheal pus. In a patient who is suffering from 
gonorrhoea and chancroids at the same time, it is therefore im- 
possible to say, before the inguinal abscess has broken, whether 
it originated from the absorption of the gonorrheal or chan- 
crous pus. After it has broken open it may be diagnosed as 
being probably a case of chancroid bubo. A positive diagnosis 
that the glandular abscess is a chancroid bubo, or, more cor- 
rectly speaking, a glandular chancroid, can only be made from 
the course of the abscess, and the result of inoculations made 
with the pus from the abscess. 

If the glandular swelling opens spontaneously, or is opened 
by the surgeon, a thick, cream-like pus escapes, like that 
from other acute abscesses ; but, in chronic suppurating lym- 
phatic swellings, thin pus containing cheesy particles, like 
that of cold abscesses, is discharged. If some of the matter 
from the abscess, taken indiscriminately, is inoculated under 
the skin, a pustule will form in some cases, which may become 
transformed into a chancroid ulcer ; in others, again, it soon 
dries up and forms a crust. If, however, an inoculation is 
made with matter taken from the bottom of the abscess, from 
a spot where two or three niche-like excavations are found, the 
pustule produced will almost always be transformed into an 
ulcer. These excavations are distinguished by the fact that 
their bases appear to be more jagged and covered with a larger 
amount of molecular detritus than the rest of the bottom of 
the abscess. From all indications they are the depots of those 
lymphatic glands to which the chancroid virus was conveyed 
by the lymphatic ducts. 



134 PATHOLOGY AJSTD TREATMENT OF SYPHILIS. 

The opening of an abscess, however, does not terminate 
the morbid process that has become established in the glands 
and adjacent connective tissne, as is the case in ordinary ab- 
scesses of the glands, or of the cellular tissue ; for instance, in 
gonorrheal buboes, in which the latter, after being opened, 
quickly become smaller and cicatrize. The chancroid virus that 
was transported to the glands and connective tissue produces 
its characteristic effects here, as in a soft chancre of the skin. 
The bottom of the abscess secretes a thin, ichorous fluid, which 
corrodes the adjacent tissues, especially the margins of the ab- 
scess, undermining them and giving them a jagged appearance. 
An ulcer of the skin, which gradually enlarges and has the 
characters peculiar to a cutaneous chancroid, originates from 
this abscess. Sometimes the margins of the ulcer are under- 
mined and almost deprived of nutrient vessels, livid in color, 
and slightly overlap the bottom of the ulcer. In other cases, 
the margins proliferate, and undergo a condition of sclerosis, 
becoming everted and forming a wall of cicatrized callosity. 

A period of eight, ten, or more days may elapse from the 
time a virulent bubo begins until distinct fluctuation is felt. 
The softening which takes place sooner or later depends main- 
ly upon the behavior of the patient and the care with which 
the chancroid is treated, and also upon his constitutional con- 
dition. Glandular chancroids require a longer time to run 
their course than chancroids of the skin or mucous membrane, 
because glandular tissue and connective tissue heal much more 
slowly than ordinary skin and mucous membrane. All forms 
of disturbances of nutrition, such as scrofula, tuberculosis, 
scorbutus, etc., exercise greater influence over the ulceration 
produced by a bubo than over a soft chancre of the skin. 

In favorable cases, the abscess closes by the end of the 
fourth week after it was opened. During this period the open 
bubo may present all the morbid changes that are observed in 
a chancroid on the skin. It may be attacked by phagedena, 
and the phagedena may assume a serpiginous character. The 
surface of the ulcer may become covered with a diphtheritic 
membrane. Lastly, the bubo may also become gangrenous. 
The loose connective tissue in which the glands generally are 
imbedded is more readily destroyed by the inflammatory pro- 



SOFT CHANCRE OR CHANCROID. 135 

cess, and hence bubo-ulcers, especially the gangrenous variety, 
occasionally assume inordinate proportions. Fistulse may form, 
undermining and destroying the tissues, and by eroding blood- 
vessels cause haemorrhage that may endanger life. 

The closing of a glandular chancroid takes place in the 
same manner as in a chancroid of the skin, partly by the 
formation of cicatricial tissue from the periphery toward 
the center, and partly by the retraction of the integument. 
Large glandular chancroids, however, do not cicatrize as quickly 
as soft chancres of the skin. At the bottom of the latter the 
tissues are of a homologous nature, while fascia, hypertrophied 
and ulcerating glands and lymphatic vessels forming arches 
and prolongations are found in a bubo. The glandular chan- 
croid offers numerous conditions which are favorable to the 
decomposition of animal matter. Under the influence of gen- 
eral morbid conditions, such as hospitalism, or in consequence 
of irritating dressings and ointments, the proliferating granu- 
lations suddenly become pale, wilted, and collapsed, and under- 
go cheesy or gangrenous degeneration. ISTot only is the cica- 
trization interfered with by these morbid conditions, but the 
growth of pus-cells is greatly fostered. 

The restitution of the epidermis, as a rule, progresses from 
the margins of the ulcer, or small islands of epithelial cells 
spring up at a distance from the margin. 

Chancroid buboes occur more frequently in men than in 
women, owing doubtless to the fact that in the latter most soft 
chancres are situated upon the mucous membrane of the gen- 
ital organs, and also because females, as a rule, lead a more 
quiet life. 

Site, Shape, and Size of Chancroid Buboes. 

As a rule, the glands situated nearest the chancroid become 
affected. The chancroid virus seldom overleaps adjacent 
glands and attacks those at a distance. Thus, in consequence 
of a soft chancre on the genital organs, the inguinal and femo- 
ral glands ; on the lips or tongue, the submaxillary and sublin- 
gual ; on the fingers, cubital or axillary, or also the jugular or 
subclavical glands of the corresponding extremity, become af- 
fected. The inguinal glands are not always affected on the 



136 PATHOLOGY AND TREATMENT OF SYPHILIS. 

side corresponding to the situation of the chancroid on the 
genital organs. The soft chancre may be situated on the right 
side, while the inguinal glands on the left are diseased, or the 
reverse is the case. This fact is explained by the anastomosis 
of the absorbent lymphatic vessels. Chancroids situated upon 
the median line of the penis, especially those on the fraanum, 
are apt to produce tumefaction of the lymphatic glands on 
both sides. Fissures in the folds of the mucous membrane of 
the anus, ulcers or furuncles on the tuber ischia or on the bui> 
tocks, likewise give rise to swelling of the inguinal lymphatic 
glands. 

- The glands found in the inguinal triangle are divided into 
the superficial and deep by the fascia of the region. The su- 
perficial glands are numerous, covered by the fascia superfici- 
alis, and lie imbedded in the meshes of adipose tissue ; there 
are only three or four (sometimes only one) deep glands which 
lie directly upon the sheath of the femoral vessels. 

The superficial inguinal glands are affected much more fre- 
quently than the deep, and when the latter are affected, in 
consequence of a soft chancre, it is not caused directly, but by 
imbibition from a superficial suppurating gland or the contigu- 
ous connective tissue. Suppuration of the deep glands is much 
more dangerous than that of the superficial ones. 

The form of the glandular tumor is more distinct in lean 
persons than in stout ones, and thus it often happens that in 
women with pendulous abdomens no swelling can be seen, al- 
though they may have suffered from febrile phenomena and 
complained of pains in one of the inguinal regions for several 
days. Acute chancroid buboes vary in shape. Inguinal swell- 
ings of the lymphatics are generally elliptical ; their principal 
axis is in a line with the inguinal fold. Axillary and jugular 
glandular tumors are usually round. 

A glandular swelling formed by the inflammation of one 
gland only will present a smooth surface ; but if several adja- 
cent glands are involved, it will present, at least at the begin- 
ning, an uneven, hilly lump. This form of swelling of the in- 
guinal glands not infrequently acquires a shape like a wallet, 
owing to Poupart's ligament being stretched transversely 
across it. 



SOFT CHANCRE OR CHANCROID. 137 

The size or circumference of the glandular swelling de- 
pends, above all, upon the constitutional condition of the patient. 
Thus, large buboes form in scrofulous persons when affected 
with chancroids. It seems that the chancroid virus in these 
patients causes more irritation and increase of hyperplastic 
exudation into the glandular substance than destructive action. 
Hence, under appropriate treatment, resolution of the bubo is 
soon achieved ; but should purulent degeneration occur, which 
usually happens by the third or fourth week after the swelling 
has appeared, it will only affect the connective tissue surround- 
ing the glands, while the glandular parenchyma escapes. In 
these cases, fistulse often result. This kind of glandular in- 
flammation is known as strumous buboes. 

It is more difficult to demonstrate suppuration of the glands 
than of the subcutaneous cellular tissue, because the former 
are situated at a greater distance from the skin than the lat- 
ter. In buboes formed of many glands, not infrequently cheesy 
degeneration or purulent foci develop, and gradually either 
coalesce into a common cavity or rupture separately, forming 
multiple buboes. 

Differential Diagnosis and Prognosis of Buboes. 

Buboes of the groin, before they are open, may be mistaken 
for an inflamed testicle that has been retained in the inguinal 
canal ; for a strangulated or reducible hernia ; and, lastly, for a 
varix of the vena saphena at the point where it dips into the 
vena cruralis. 

The diagnostic features of a non-descended inflamed testicle 
are : The absence of one testicle from the scrotum ; the pecul- 
iar pain on touching the swelling ; and, lastly, its characteristic 
hardness. Glandular swellings, before pus has formed in them, 
are harder to the touch than a testicle. An epididymitis, in 
addition, is distinguished from a suppurating bubo by the ab- 
sence of softening. The symptoms of a reducible hernia are : 
The tumor is soft, compressible, and becomes smaller when the 
patient assumes a horizontal position — larger when he stands, 
coughs, or sneezes. On pressing an enterocele, borborygmi are 
heard, and, attended by a gurgling noise, the prolapsed gut 
slips back into the abdomen. In strangulated hernia there 



138 PATHOLOGY AND TREATMENT OF SYPHILIS. 

are, in addition to the general symptoms, colic-pains, flatulence, 
etc. The percussion-sound is generally tympanitic. Later, 
the symptoms of inflammation and the evidences of gangrene 
ensue, followed by vomiting of stercoraceous matter. 

The characteristic symptoms of varix are : The rise and 
fall of the tumor, synchronous with inspiration and expira- 
tion, its increased tension when the saphena vein is com- 
pressed above it, and its collapse when the vein is compressed 
below it. 

Open inguinal buboes are apt to deceive the physician by 
the similarity they sometimes present to epithelial carcinoma 
situated in the inguinal region. In regard to the differential 
diagnosis, we refer the reader to what has been said concern- 
ing the differential diagnosis between a soft chancre and epi- 
thelioma. 

The character and ultimate result of a bubo can not be 
definitely decided at its commencement. It is only possible 
to infer from the existing or preceding chancroids that the be- 
ginning bubo is the result of absorption of the chancrous virus, 
and that it will inevitably suppurate. But if the chancroid 
was cicatrized long before the bubo began, we are justified in 
assuming that the pus from the soft chancre was brought to 
the glands at a time when the former was no longer virulent, 
and in this event suppuration need not necessarily ensue. The 
constitutional condition of the patient, his behavior, and the 
character of the chancroid, play an important part, and should 
be taken into consideration in forming a prognosis. In feeble, 
anaemic, scrofulous, tuberculous, and cachectic persons, the sup- 
puration and cicatrization of a bubo never progress satisfac- 
torily. Not infrequently they are interrupted by the super- 
vention of a gangrenous, inflammatory condition of the sub- 
cutaneous cellular tissue, especially when the patient is confined 
in an unhealthy atmosphere — for instance, in a hospital. Vio- 
lent exercise aggravates the inflammation and the tendency to 
suppurate. The greater the number of the glands affected, 
the larger the abscess will be, and the longer the cavity will 
take to cicatrize. If the soft chancre becomes phagedenic, 
the suppurating bubo will also assume a phagedenic character. 
Gangrenous buboes are exceedingly dangerous. The hyper- 



SOFT CHANCRE OR CHANCROID. 139 

plastic enlarged glands, having been deprived of their capsules, 
project into the cavity of the abscess and prevent its cicatri- 
zation. 

Treatment of Diseases of the Lymphatic Vessels produced by 

Chancroids. 

In inflammation of the lymphatic vessels of the dorsum 
of the penis, however it may be produced, the organ is to be 
put on the abdomen and wrapped in compresses dipped in 
ice-water. Suppurating bubonuli should be incised, and the 
open lymphatic abscess, if it has originated in consequence of 
a soft chancre, treated precisely like a chancroid on the skin. 
If evidences of inflammation of the lymphatic vessels ap- 
pear, no irritating caustics or lotions should be applied to 
the chancroid. 

Treatment of Buboes before they are opened. 

The abortive treatment may be resorted to in the hope 
of arresting the beginning inflammation of the glandular and 
connective tissue, and of avoiding or limiting suppuration. In 
buboes caused by soft chancres it is seldom successful ; it may 
prove more successful in contagious catarrhs of the urethra or 
the glands, in swelling of the glands due to a syphilitic initial 
chancre, or in cases in which a simple lesion in coexisting 
scrofula was the cause of the glandular swelling. 

First of all, everything should be avoided that may increase 
the irritation of the glands. The patient must stay in bed ; 
but, in torpid, strumous buboes of cachectic persons, moderate 
exercise in the open air is beneficial. Cold compresses should 
be applied to the glandular swelling, if it presents an inflamed 
rather than a hyperplastic indolent character ; but if the least 
pulmonary catarrh be present, these applications should be 
made with the utmost caution. We have found the compress 
or T-bandage to be very useful in hyperplastic swelling of 
the lymphatic glands, for the purpose of encouraging absorp- 
tion. Blisters, with or without the local application subse- 
quently of a concentrated solution of corrosive sublimate, in 
our hands, failed almost entirely. In view of the pharmaco- 
dynamic action of iodine, the tincture of iodine may be em- 



140 PATHOLOGY AND TREATMENT OF SYPHILIS. 

ployed for that purpose, painting the skin over the swelling 
with it by means of a camel's-hair brush. The irritating effects 
of this remedy may be diminished by the addition of an 
anodyne. We therefore order the following compound : 

^ Tr. iodine, 30*00 [ f j] ; 

Tr. belladonna, 10-00 [3 viij]. 
M. S. Fur external use. 

^ Tr. iodine, 30-00 [ § j] ; 
Tr. gallar., 15-00 [ § ss.]. 
M. S. For external use. 

If the skin nevertheless becomes irritated, we order iodine 
plaster instead of the tincture, in the following manner : 

^ Iod. plumbi, 5*00 [3 iv] ; 

Emplas. diachyl. comp., 50-00 [ § jss., 3 iv]. 
Ung. elemi q. s. ut fiat einp. molle. 

The plaster is spread upon muslin or soft leather, and 
applied to the glandular swelling. Iodine, after all, is best 
adapted to accomplish resolution in indolent strumous buboes. 
As the odor of iodine is disagreeable, we employ instead the 
basic acetate of lead, and have obtained at least as good results 
with it as with iodine. Compresses dipped in a solution of 
acetate of lead are applied to the swelling and changed several 
times a day, securing them to the parts with a spica bandage. 
Under this treatment the hyperemia and redness of the skin 
disappear, and the swelling diminishes in size. 

If, however, despite the application of the lead-water com- 
presses, suppuration takes place, and fluctuation is detected, 
the pus must be evacuated under strictly antiseptic precautions. 
First, the hairs should be shaved off, the parts washed care- 
fully, and while the operation is being performed a stream of 
a two-per-cent solution of carbolic acid should irrigate the 
parts. The abscess may be punctured with a sharp-pointed 
bistoury, or laid open by careful dissection with a scalpel in 
a line running along the inguinal fold. The latter course is 
especially recommended to the inexperienced. We have known 
instances in which very good physicians injured the arteria 
cruralis while puncturing a bubo. At first a small opening 
should be made : if no pus escapes at once, a blunt probe, pre- 



SOFT CHANCRE OR CHANCROID. 141 

viously dipped in the disinfecting -fluid, should be inserted 
into the wound, and the little finger (also washed in the same 
fluid) being placed in the wound to ascertain by the sense of 
touch whether any important organs are in the way, the cap- 
sule of the gland, and the glandular substance itself, should 
then be broken up. If pus be present, which is sure to be 
the case when pressure with the probe at any one spot of the 
unopened glandular tumor causes very severe pain, it will soon 
flow from the wound. A director is then passed into the 
wound, and the cavity freely laid open. It is best to remove 
the undermined skin at once, in order to have a uniform wound 
without any pockets. Any divided blood-vessel must be tied. 
Particles of the disorganized gland should be carefully scraped 
away with the scoop. 

After the operation is finished the wound should again be 
washed with a two-per-cent solution of carbolic acid, then dried 
with Brun's wadding, and powdered with iodoform; next, 
several layers of antiseptic gauze made into a compress and laid 
upon it are covered with a piece of gutta-percha cloth, and the 
whole secured by a spica bandage. This dressing must be re- 
newed every day, and the subsequent treatment of the wound 
is conducted in accordance with the general rules of surgery. 

The use of caustic pastes for the purpose of opening buboes 
has been discarded, as they are unsurgical. 

In anaemic patients, in whom very little pus is present, we 
may first attempt to puncture the abscess with Graefe's cata- 
ract-knife, allowing the pus to escape, and then applying lead- 
water compresses. In this manner, in some cases, a cure was 
achieved, the skin that had already been raised by the pus 
again uniting with the parts beneath it. 

The Treatment of Open Buboes. 

A bubo that broke open spontaneously, or was opened with 
a knife, originating in consequence of gonorrhoea or an ero- 
sion, should be treated like an ordinary abscess of the lymphatic 
glands or connective tissue. But, if it be the result of a soft 
chancre still in full progress, it is to be regarded as a chancroid 
of the glands and cellular tissue, and treated like- a soft chancre 
of the skin, taking into consideration, however,, the location 



142 PATHOLOGY AND TREATMENT OF SYPHILIS. 

and structure of the diseased foci. A glandular chancroid 
forms an ulcerating cavity in which pus mixed with tissue- 
detritus ma j easily accumulate. These cavities should, there- 
fore, be washed out several times a day, either with a syringe 
or by irrigation, or by means of sitz-baths, in which the patient 
is kept for a long time. After this the cavities should be 
packed with pledgets of cotton dipped in a solution of carbolic 
acid or chloride of zinc, chlorate of potash, caustic potash, or, 
better still, powdered with iodoform. A spica compress band- 
age should then be applied. IXypertrophied glands, whose cap- 
sules have been destroyed, and which project into the cavity of 
the abscess, should not always be cut away. It is preferable to 
paint them several times a day with a weak solution of caustic 
potash or soda, or once a day with a concentrated solution of 
nitrate of silver. We have also seen good results from filling 
the cavity with a compound consisting of balsam of Peru, 20*00 
[ 5 ss., 3 jv] aud arg. nitric, 0*05 [gr. j]. Occasionally, we 
have derived much benefit by injecting once a day a little 
basic acetate of lead, with a Pravaz syringe, into the exposed 
hyperplastic enlarged glands. Hypertrophied lymphatic cords 
should be divided with the scissors, and callous margins of the 
skin removed. In commencing gangrene, we apply an emul- 
sion of camphor, or fill the cavity of the abscess alternately 
with pledgets of cotton dipped in chloride of lime and with 
plaster of Paris and tar or iodoform, and cover the whole with 
ice-cold applications. If the gangrene can not be checked, the 
actual cautery should be employed, or the patient put into a 
bath. Lastly, the room occupied by the patient should be 
thoroughly and frequently ventilated, because in damp, dark, 
and badly ventilated rooms buboes readily assume a putrid 
character. 

Fistulae in consequence of Suppurating Buboes. 

Fistulse result either from the burrowing of pus, or they 
are the consequences of a progressive inflammation of the sub- 
cutaneous or intermuscular cellular tissue and of the cellular 
tissue of the sheaths of vessels and fascia. They run either 
superficially under the skin and fascia superficialis, or form 
sinuosities deep between the tissues. Fistulse may last for 



SOFT CHANCRE OR CHANCROID. 143 

years, and thereby render the patient cachectic. The danger 
from them increases with their extent ; those penetrating 
deeply are more dangerous than the superficial ones. At- 
tended by inflammatory phenomena, an infiltrated swelling 
forms at the external end of the fistula, which soon becomes 
soft and breaks, in many cases at a distance from the original 
abscess. As a result of this burrowing, the fistulae acquire a 
very tortuous course, having branches that lead in different 
directions, but are connected by one parent canal. They may 
become filled up with granulations whereby the lumen of their 
canals is plugged up. In consequence of these granulations, 
they may become cicatrized like cords, temporarily or perma- 
nently, or the walls are only lined with cicatricial tissue while 
the suppuration continues. 

This variety of fistulae may occur above and below Pou- 
part's ligament. Those situated below Poupart's ligament be- 
come serious when they burrow beneath the sheath of the fem- 
oral vessels and between the abductors of the thigh, or when 
they extend into the lesser pelvic cavity along Gimbernat's 
ligament. The greatest danger in fistula appears when gan- 
grene gives rise to erosion of some of the arteries — for instance, 
the circumflex. 

To prevent fistulas from forming, the physician will find it 
necessary to bring about a union of the undermined skin with 
the subjacent parts, or, by making a counter-opening, or, by 
freely laying open the abscess, to evacuate the pus. Eo fistu- 
lous tract should be laid open till all hopes of resolution are 
gone, and the inflammatory phenomena plainly indicate that 
pus has formed. With that object in view, cold- water appli- 
cations should be made, and changed as often as they become 
warm, and the tract should be compressed with appropriate 
dressings and bandage. 

The fistula may either be slit open with a scissors or bis- 
toury upon a grooved director, or a ligature may be passed 
through and allowed to ulcerate its way out. The former 
method is better adapted in superficial, straight fistulas — the 
latter in deep, tortuous ones. By the use of the ligature, 
haemorrhage is avoided, which, in a patient already exhausted, 
may prove very serious. This measure, moreover, brings about 



1M PATHOLOGY AND TREATMENT OF SYPHILIS. 

a more speedy closure of the tract than by slitting it open. 
The ligature may be either of silk well waxed, or an elastic 
drainage-tube. 

By means of a probe armed with the ligature or drainage- 
tube, an effort is made to find the terminal opening of the 
fistula. If it terminates at a point on the skin in the vicinity, 
the instrument is pushed through, and one end of the ligature 
is brought out at the lower opening ; but if the tract termi- 
nates blind, and the point of the probe is felt beneath the 
skin, the probe should be withdrawn, a grooved director in- 
serted, and an incision made with a bistoury on its point ; after 
which the probe, armed with the ligature, may be passed 
through the fistula. If the tract penetrates perpendicularly 
into the tissues, an effort should be made, by inserting into 
it compressed sponges, laminaria, or the like, to convert it into 
a funnel-shaped cavity, whose larger aperture is directed out- 
wardly, and by the application of stimulating dressing make 
it close up. If this fails, a drainage-tube of the proper length 
and thickness should be inserted. Finally, by cleansing the 
fistula frequently, and by applying caustic or antiseptic reme- 
dies, such as weak solutions of caustic potash or carbolic acid, 
Lister's paste or iodoform, a union of its walls may be brought 
about. If a lardaceous membrane (fatty and molecular de- 
generated connective tissue) forms along the fistulous passage 
that has been laid open, pledgets of lint dipped in a weak so- 
lution of caustic potash, acetate of iron, iodo-glycerine, or 
chloride of zinc, should be applied once or twice daily. 



SECTION III. 
SYPHILIS. 

General Conception. 

By the term syphilis is meant a blood-poisoning, produced 
by a peculiar animal virus, as the result of which various mor- 
bid lesions, occurring in a more or less constant series, are oc- 
casioned in the different tissues of the human body, and in 
which the specific inflammatory products, and the blood from 
the affected person, when transmitted to other healthy persons, 
produce in the latter similar morbid effects. 

Nature and Vehicle of the Syphilitic Virus. 

The syphilitic contagion adheres to all textural elements 
and textural detritus ■ produced by suppuration or bionecrosis 
in consequence of syphilis. It is most abundant in disorganized 
syphilitic papules and the sloughing initial sclerosis or hard 
chancre. The blood and semen of virile syphilitic persons do 
not seem to be totally, and at all times, tainted with the syphi- 
litic element. In this way may be explained the variable re- 
sults obtained from inoculations with the blood from syphilitic 
persons, and the fact that a syphilitic father will at one time 
beget a healthy child, and at another a syphilitic one. The 
milk, saliva, tears, and urine, do not seem to form a vehicle 
for the transportation of the syphilitic virus. Hence those 
pathological secretions that have no connection with syphilis — 
for instance, gonorrheal discharges, the matter from eczema, 
the sputa of pneumonia in a syphilitic person — can only be- 
come infectious syphilitically when they are mixed with syphi- 
litic blood or syphilitic detritus. 
10 



146 PATHOLOGY AND TREATMENT OF SYPHILIS. 

The contagion of syphilis, from all accounts, is a fixed 
principle. There is no snch thing as syphilitic miasm. Neither 
the microscope nor chemistry has so far been able to furnish 
us with any more definite information regarding its nature. 
Some authors claim to have discovered a peculiar micro-organ- 
ism which is present in the blood and the morbid lesions, and 
which engenders the syphilitic disease; unfortunately, how- 
ever, the discovery still lacks confirmation. 

The Transmissibility of Syphilis, or the Various Ways in 
which Syphilitic Infection may take place. 

Syphilis may be transmitted either directly by contact 
with syphilitic tissue-elements or by procreation on the part 
of syphilitic parents. The manifestations of the first form 
are called " acquired " syphilis {syphilis aequisita), those of 
the latter hereditary syphilis (syphilis hereditaria). The con- 
tagion of syphilis being, as stated, a fixed principle, it begins 
to manifest itself at some given point, and thence infects the 
entire system. The infection of the system must be preceded 
by a solution of continuity, and it is entirely immaterial whether 
it is produced at the same time or some time before the syphi- 
litic virus took effect. The uninjured epidermis, as a rule, 
forms a protection against infection by syphilis. In most cases 
the lesion and the infection take place through coitus, during 
which, by friction or maceration, the epidermis or the epithelial 
layer at some point on the genital organs is abraded, and the 
denuded spot on the skin or mucous membrane is readily acted 
on by the syphilitic virus. The virus may, however, also gain 
an entrance into the system through many other places — for 
instance, the mouth, tongue, cheeks, eyelids, forehead, nipples, 
fingers, etc. The transmission is either direct from a dis- 
eased to a well person, or it is indirect. The direct transmis- 
sion of the syphilitic virus usually takes place during coition, 
kissing, wet-nursing, operations by surgeons, midwives, nurses, 
etc. The indirect infection may occur by utensils, cigar-hold- 
ers, pipes, surgical instruments, bandages, etc. Even persons 
who are well may serve as agents in transporting the virus 
without becoming themselves affected, simply affording a tem- 
porary shelter for it at some place on their bodies — for instance, 



SYPHILIS. 147 

in the vagina, or under the nails. The syphilitic contagion, 
under favorable circumstances, may give rise to syphilis in all 
persons who hitherto had not been affected with it. ]STo age, 
no temperament, and, as it seems, no nation, have, as regards 
syphilis, any special immunity, nor again any special suscepti- 
bility. Syphilitic tissue-elements retain their powers of infec- 
tion for a long but uncertain period ; syphilitic papules, for 
instance, are capable of communicating the disease after many 
months. 

Transmission of Syphilis by Vaccination. The Relation of Vac- 
cine Lymph to Syphilitic Virus. 

During the early part of this century many physicians re- 
ported numerous instances in which, in consequence of vacci- 
nation, hard, protracted, indurated ulcers formed at the site of 
vaccination, followed subsequently by syphilitic eruptions of 
the skin. The question now arises, How is the transmission of 
syphilis, in consequence of vaccination, brought about ? Our 
opinion is, that syphilis can only be transmitted by vaccination 
when syphilitic germ-elements are transplanted at the same 
time with the vaccine lymph. These elements are the blood of 
a syphilitic person, and the molecular detritus, or the pus origi- 
nating from syphilitic eruptions. We only agree in the opin- 
ion of Yiennois in so far as to admit that in some cases syphi- 
lis may be transmitted by means of the vaccine lymph taken 
from a syphilitic person, when the vaccine virus becomes 
mixed with some blood from that patient. This manner of 
transportation also serves partially to explain the fact that, in 
the class of vaccinations in which blood has simultaneously 
been transported, only a few of the vaccinated became syphi- 
litic. The experimental inoculations of healthy persons with the 
blood of syphilitics have shown that the results vary very much. 
Those inoculations in which some syphilitic blood was trans- 
mitted with the lymph taken from a normal vaccine vesicle 
correspond to those cases of vaccinal syphilis, in which a cir- 
cumscribed, hard initial node formed at the place of vaccina- 
tion after the vaccine vesicle had gone through the successive 
stages of normal development, dried into a crust, and sub- 
sequently fell off. Syphilis may, however, also be transmit- 



148 PATHOLOGY AND TREATMENT OF SYPHILIS. 

ted in vaccinating with lymph, taken from a syphilitic per- 
son, and mixed with tissue detritus resulting from syphilitic 
disorganization. The results of the inoculations which Pick 
and Krause obtained by using the matter of bullous or pustu- 
lar eruptions on syphilitic persons justify us in assuming that 
in patients affected with latent or florid syphilis, if vaccinated 
with cow-pock virus, a vesicle or pustule may be produced 
that gradually develops into a little ulcer. JSTow, such a vesi- 
cle situated upon a syphilitic patient may be mistaken for a 
vaccine vesicle, and its contents, if used, may serve as a means 
of transmitting syphilis ; the disease is sure to be transmitted 
if some of the pus it contains is used. 

This view also serves to explain the fact that in some 
cases the vaccinations failed, and yet at about the end of 
the third week after the person w T as vaccinated a circum- 
scribed syphilitic sclerosis of the tissues developed at the 
point of vaccination. 

The theory that vaccine lymph in its passage through a 
syphilitic system likewise becomes syphilitic, i. e., acquires the 
property of syphilis in addition to being cow-pox, is refuted by 
numerous vaccinations performed upon healthy persons by 
some of the most reliable investigators who used vaccine lymph 
taken from syphilitic patients, and invariably produced normal 
cow-pox — never syphilis. Were the cow-pox lymph of syphi- 
litic individuals charged with the contagion of vaccine and of 
syphilis, every person that is successfully vaccinated with it 
would also become affected with syphilis. But this does not 
happen. 

From the preceding remarks it is evident that the follow- 
ing rules should be observed in performing vaccination : 

(1) The child from whom the vaccine virus is taken, and 
his parents, should be subjected to a most careful examination. 

(2) In view of the faet that congenital syphilis rarely 
breaks out before the end of the third week after birth, no 
vaccine lymph should be taken from a child under eight weeks 
of age. (See Hereditary Syphilis.) 

(3) "No vaccine lymph mixed with blood or pus should be 
used under any circumstances. 

[The surest way of avoiding transmission of syphilis by 



SYPHILIS. 149 

vaccination is to discard humanized vaccine entirely, and use 
animal vaccine lymph only.] 

Transmissibility of Syphilis to Warm-blooded Animals. 

Whether syphilis can be transmitted to animals, and pro- 
duce in them manifestations similar to those produced in man, 
is still an open question. While some investigators — for ex- 
ample, Klebs and Martineau — report successful inoculations in 
apes and hogs, neither Neumann nor myself succeeded in pro- 
ducing either a primary local effect or any other manifestation 
of lues by inoculating this class of animals with syphilitic pus 
or blood. In one ape whom we inoculated in three places on 
the back with the pus of a soft chancre, we succeeded in pro- 
ducing pustules which soon became converted into ulcers that 
healed within three weeks. Many similar experiments fur- 
nished us equally striking proof of the difference between a soft 
chancre and syphilis. 

First Manifestations of the Action of the Syphilitic Virus. 

The first manifestation of the action of syphilitic poison is 
presented at the spot where the virus was deposited and ab- 
sorbed. The first external manifestation that appears at the place 
of infection varies, however, according as the syphilitic con- 
tagion is associated with an irritative factor, i. e., pus or ichor, 
or with some harmless ffuid, such as blood, serum, or lymph. 
In the former event, there appears at the place a circumscribed 
hyperemia and swelling, the latter passing in a few or several 
days into a condition of purulent softening or ulceration of the 
tissues. The swelling and suppuration appear there all the 
more quickly and more intensely, the deeper the solution of 
continuity through which the syphilitic virus took effect. The 
tissues, in persons who had not been previously affected with 
syphilis, do not assume for a long while at the place of infec- 
tion those pathognomonic alterations which we would recog- 
nize as evidences of luetic infection. But if the infecting con- 
tagion was not combined with pus-cells, but only with such 
fluids as are usually secreted on the superficial surface of the 
sclerotic ulcer {intercellular exudation), or with the blood of a 
syphilitic individual ; and, above all, if at the place of infection 



150 PATHOLOGY AND TREATMENT OF SYPHILIS. 

there was no deep solution of continuity, but only a sim- 
ple excoriation — no suppuration will take place, and the ex- 
coriation will heal quickly. After a longer or shorter period 
{first period of incubation), a nodule, varying in size, will 
form. At the junction of integument with the mucous mem- 
brane this resembles a moist papule that is just beginning 
to grow. 

Kepeated observations, however, have taught us that per- 
sons affected with latent, feeble syphilis, though having no 
syphilitic effects on any part of their bodies, may communicate 
the disease to their wives, although it is not possible to dis- 
cover any initial syphilitic lesion in the latter, and have not 
become pregnant. In these women syphilis manifests itself 
by extremely rapid emaciation. In the further course of the 
disease they lose their hair; sometimes periosteal pains and 
swellings come on on some of the bones, and subsequently the 
menses become profuse and recur frequently. On becoming 
pregnant they will often abort. In what manner the syphi- 
litic contagion, in such cases, has gained an entrance into the 
system, is not yet clearly known. We know just as little in 
what manner a woman who suffers from latent syphilis is capa- 
ble of communicating the disease to her husband. Possibly, 
in such cases, the blood has served to transmit the infection, 
some bleeding erosions or excoriations having occurred on the 
genital organs. 

In those cases in which the action of the luetic virus mani- 
fests itself in the form of an ulcer, the tissues at the base of 
the ulcer begin, at the end of the third or fourth week, to con- 
dense more or less markedly, or, if it is already cicatrized, the 
cicatrix becomes hard. If the action of the virus began in 
the form of a nodule, molecular disorganization will ensue a 
few days after it appeared. The disorganization is confined 
either to the upper layers, the epidermal or epithelial covering 
only being destroyed, and the infecting focus simulates an 
erosion, or the disorganization extends deeply into the nodule, 
and sometimes occasions a marked loss of substance. The 
solidification of the tissues at the base of the ulcer and the 
growth of the nodule are identical processes, and both of them 
give rise to that gradual hardness and increasing induration of 



SYPHILIS. 151 

the tissues which are designated by the term initial sclerosis 
of syphilis. 

The sclerosis does not originate at once, but gradually, and 
develops with well-marked remissions. For a time it is at a 
stand-still in its development, and then it suddenly takes a for- 
ward step. It may attain the size of a lentil, pea, or bean ; it 
may also extend over a large area of tissue. The lips, the labia 
majora or minora, or the skin over half of the glans or body of 
the penis, may become indurated. Absorption begins in the 
center of the induration, as is shown by the diminished hard- 
ness of the tissues at this spot. After the hardness has entirely 
disappeared, a bluish-red discoloration, corresponding in size to 
the induration, remains behind. The discolored spot gradually 
grows pale, finally becoming whiter even than the normal skin 
{pigment atrophy). If the induration disappears by absorp- 
tion, a central depression only will form ; but if the induration 
undergoes disorganization a depressed cicatrix will remain. 

Anatomy of the Syphilitic Initial Sclerosis. 

The macroscopic picture of a syphilitic initial sclerosis va- 
ries according as it has developed upon an ulcerated or eroded 
spot on the skin, or is undergoing development or resolution. 
If a cutaneous ulcer acquires a sclerotic condition through the 
reception of syphilitic virus, the solidification of the tissues 
will, at first, be limited to the margins and base of the ulcer ; 
gradually, however, the parts beyond also become affected. If 
no noteworthy loss of substance, either through injury or ulcer- 
ation, took place at the point of infection before infection oc- 
curred, an infiltrated node will form, which gradually increases 
both in circumference and in depth, grows harder and denser, 
and finally forms a firm tubercle with well-defined outlines, 
which sometimes feels like a solid encapsulated piece of carti- 
lage. The upper surface of the infiltrated spot may in a few 
days undergo ulceration, in consequence of granular degenera- 
tion. An ulcer, varying in form and extent, may thus be pro- 
duced ; it presents a flesh-colored, finely granular, readily bleed- 
ing, velvety appearance, secreting a thin, sometimes gummy 
discharge, in which are found a very few pus-cells. Here, too, 



152 PATHOLOGY AND TREATMENT OF SYPHILIS. 

the space beyond the line of deroarkation surrounding the 
ulcer very slowly undergoes sclerosis. 

In consequence of the pressure which the sclerotic node 
exercises upon the capillary vessels of the affected tissues the 
supply of blood to the parts is diminished to such a degree 
that, when the node is incised, a sound is heard like that 
produced by cutting cartilage, and very little blood flows. 
This pressure upon the capillary vessels may also be the reason 
why the sclerotic tissue is not removed by softening and suppu- 
ration, but is destroyed by the slower process of fatty degenera- 
tion and absorption, or by necrosis, layer by layer from without 
inward. External and local influences, such as friction, cauteri- 
zation, etc., may bring about a more rapid degree of necrotic 
disorganization of the sclerotic tissues. Softening and puru- 
lent infiltration then become superadded, and extensive de- 
struction will ensue. In addition, a large or small part of the 
necrotic tissue may be destroyed by gangrene, and the node 
may then become so excavated as to leave only a hard shell 
behind. After the slough has been cast off and a permanent 
cicatrix formed, this will give it the characteristic hardness. 
This process differs from the sloughing that takes place in a 
soft chancre by the fact that the latter destroys normal tissues, 
while in syphilitic initial ulcers morbid products that have 
been deposited are destroyed. 

Sclerotic places that have undergone necrosis cicatrize yery 
slowly, and even when they have fairly cicatrized they do 
not always remain so, since syphilitic sclerotic cicatrices often 
break open again. This may happen so long as the sclerotic 
tissues are not entirely absorbed and replaced by perfectly 
normal material. After the sclerosis has disappeared, an exca- 
vation results, in consequence of atrophy that has begun in the 
center, and this has a semiotic significance. 

Under the microscope, the initial sclerosis of syphilis pre- 
sents very dense cellular infiltration which is not particularly 
characteristic. The cellular infiltration affects the papilla of 
the skin and the subcutaneous connective tissue, and is espe- 
cially abundant in the adjacent tissue of the blood-vessels, the 
adventitia of the latter being frequently involved in the infil- 
tration. In most instances the lumen of the vessels is only 



SYPHILIS. 153 

diminished in size ; still, they may also be entirely occluded. 
We agree with Ziegler that the induration of the primary 
lesion of syphilis is produced by the long persistence of the 
libers of the connective tissue, notwithstanding the profuseness 
of the infiltration. The majority of the cells are small ; some- 
times they are large, epithelioid ; some of them have numerous 
granules. If the primary luetic lesion undergoes resolution 
without disorganization, a markedly discolored spot remains in 
its place, which subsequently becomes perfectly normal. If 
the node undergoes suppuration, a scar will remain. 

Site and Form of the Hunterian Induration. 

There is no place on the common integument on a person 
unaffected with syphilis at which a Hunterian chancre can 
not originate. No place possesses any immunity, neither does 
any possess a special qualification for producing it. It occurs 
most frequently on the genital organs of both sexes. In the 
male, on the internal surface of the prepuce, on the glans in 
the fossa coronaria, on the frsenum, and on the penis gener- 
ally ; in the female, mostly on the edges of the labia, at the 
anterior and posterior commissure, and on the prseputium cli- 
toridis. On the mucous membranes, the sclerosis is less dis- 
tinctly marked in general, and sometimes is totally overlooked. 
Hence it happens that, on the parts of the female genital or- 
gans, where infection naturally occurs most frequently — for in- 
stance, in the vestibule and introitus vaginae — a sclerotic node is 
very seldom detected on the mucous membrane. On the other 
hand, it develops more distinctly on the os uteri, where, how- 
ever, it can only be definitely diagnosed by the aid of a uterine 
speculum, into which the indurated os uteri does not glide like 
a normal os, but shoots in in consequence of the elasticity it 
has acquired through the Hunterian induration. If the specu- 
lum be pressed against the indurated os, or if pressure is made 
upon the latter with a wooden rod through the instrument, 
the fibro-plastic material deposited in the part will appear like 
a mass of transparent mother-of-pearl. 

Hunterian indurated chancres may be produced on the con- 
junctiva of the eye, on the mucous membrane of the nares, on 
the cheeks and chin, by transportation with the fingers and 



154: PATHOLOGY AND TREATMENT OF SYPHILIS. 

under the nails, and by kissing. Sclerotic chancres on the 
lips and tongue of both sexes occur by kissing, sexual deprav- 
ity (cunnilingus\ by transmission by the agency of utensils, 
pipes, etc. Indurated chancres on the lips generally extend 
only as far as the vermilion border, and seldom reach beyond 
it to the mucous membrane. The Hunterian initial sclerosis 
is frequently seen upon the nipples of the breast, where it 
originates in wet-nursing syphilitic children. It often occurs 
on the fingers. Only one syphilitic initial sclerosis, as a rule, 
is met with on a person ; but, if several places become infected 
at the same time, all the parts are apt to become indurated. 

The form of the induration depends upon the character of 
the infected portion of the skin, and also upon the depth to which 
the syphilitic virus has penetrated. The deeper the virus pene- 
trates into the tissues, the more pronounced will the induration 
be; the more spongy the tissues of the infected place, the 
more diffused will it be. If the syphilitic poison has pene- 
trated below the integument, round or semicircular nodules, 
as hard as fibroids, will originate. If, during infection, the le- 
sion affected only the epidermis layer, and the solution of con- 
tinuity is an extensive erosion or excoriation, the induration of 
the tissues will be like a thin plate, having the hardness of 
chondroid tissue, and the fingers experience a sensation on 
pinching up a fold of the skin as if a bit of parchment is 
imbedded in the sore {chancre jparcheminee of Eicord). This 
last form occurs almost exclusively on the mucous membrane 
of the prepuce, where in retracting it the chancre becomes 
everted in the same manner as one everts the tarsal cartilage of 
the eyelid. In addition, it possesses the peculiarity of cica- 
trizing with surprising quickness. Frequently the phimotic 
prepuce becomes converted into a hard, dense, cartilaginous 
•funnel. In congenital constriction of the prepuce, the lips of 
the foreskin are often lacerated during intercourse in several 
places, into which the syphilitic virus is apt to be deposited, 
and all the lacerations afterward become indurated. The orifice 
of the prepuce then becomes converted into a dense ring, pro- 
ducing almost total phimosis, that is not relieved until resolu- 
tion of the indurated deposit has taken place. If the poison 
of syphilis adheres to one of the sebaceous follicles— a condi- 



SYPHILIS. 155 

tion that generally happens when a follicle is deprived of its 
epithelium by seborrhceal disease — the induration that then 
takes place in the follicle will assume the form of a cylinder 
standing on end. But if a number of contiguous sebaceous 
glands become infected, as is often the case in those situated 
in the fossa coronaria of the glans penis, a hard wall originates 
from the coalescence of these indurated glands and encircles 
the glans like a wreath. If both, lips of the meatus in the 
male are the site of the syphilitic infection, the orifice becomes 
transformed into a dense, patulous, funnel-shaped opening, which 
feels like cartilage. 

Combined Effect of the Syphilitic Virus and of the Chancroid 

Virus. 

In the same way that an individual may be infected at the 
same time or in succession on two different parts of the body 
— on the genitals with a soft chancre, on the lips with a con- 
stitutional ulcer or syphilitic chancre — so both poisons, that of 
the soft chancre and of constitutional syphilis, may be depos- 
ited on the same part of his person simultaneously, or one after 
another. In such a case, both contagions may develop their 
local effects together. The chancroid develops and the indu- 
ration follows ; indeed, if both poisons are deposited at the 
same time and place, the soft chancre will have been far ad- 
vanced before the induration manifests itself. Generally, this 
does not occur till the eighteenth or twentieth day from the 
time the chancroid appeared. If the syphilitic virus has been 
absorbed several days before the poison of the soft chancre was 
deposited on the same spot, the induration will appear a few 
days after the chancroid. If a soft chancre is inoculated upon 
a syphilitic indurated base, it will display all the modifications 
it usually shows on the normal skin and mucous membranes. A 
superficial and deep phagedenic, or other variety of chancroid, 
may originate upon a syphilitic, indurated chancre. In the 
latter case, the phagedena will destroy the induration, and the 
chancrous ulcer will be surrounded like a hard shell by the ex- 
cavated indurated tissue. But if the induration was in process 
of development when the infection with the chancroid took 
place, the tissues adjacent to the phagedenic chancre will be 



156 PATHOLOGY AND TREATMENT OF SYPHILIS. 

destroyed by tlie phagedena, and the induration will spread 
peripherally in the contiguous tissues that are unaffected by 
the soft chancre. In both cases the cicatrization of the chan- 
croid progresses very slowly. This, we think, is due to the 
fact that no retraction of the skin can take place here, because 
the chancroid is surrounded by indurated tegumentary tissue. 
Cicatrization is effected by a process of new growth, connect- 
ive tissue fibrillae effecting, in this way, the closing up of the 
ulcer, while the rest of the original induration now surrounds 
the cicatrix like a wall in the form of a hard ring that fre- 
quently desquamates (circular induration). Under general anti- 
syphilitic treatment the fibro-plastic exudation will be absorbed, 
rendering it possible for the retraction of the skin to take place, 
and expediting cicatrization. 

Inoculability of the Sclerotic Ulcer. 

As has been repeatedly stated, inoculations with the dis- 
charges from syphilitic infecting foci, especially suppurating 
initial indurations and syphilitic papules, will produce pus- 
tules and ulcers in those affected with these lesions, and in 
other syphilitic persons. Hence, the auto-inoculability of an 
ulcer upon a person affected with it is of no great value as a 
diagnostic aid for the purpose of deciding whether an ulcer is 
a syphilitic initial sore or a simple venereal sore (chancroid). 
This is all the more true, since even pus of n on- venereal origin 
will produce on syphilitic persons a series of inoculable ulcers. 

Therapeutically, however, the auto-inoculation of syphilitic 
infecting foci must be taken into consideration for the purpose 
of carefully isolating suppurating sclerotic indurations and 
syphilitic papules, lest they produce ulceration by impression 
upon adjacent normal tissues. 

Significance, Duration, Course, and Differential Diagnosis of the 
Syphilitic Initial Sclerosis [Hard Chancre]. 

A fully developed syphilitic initial sclerosis is of the ut- 
most importance from a diagnostic and prognostic point of 
view, because from the moment it originates the effects of the 
commencing syphilis may be recognized. The patient is un- 
der the influence of the syphilitic diathesis so long as the in- 



SYPHILIS. 157 

duration lasts, and it only becomes less significant when it has 
entirely disappeared along with the constitutional phenomena. 

Left to itself, a primary induration that is situated upon 
the common integument will undergo desquamation attended 
by repeated congestions of the part. The epidermal covering 
of the induration, which is frequently renewed, has a peculiar 
glossy appearance and dark-brown color merging into redness. 
The upper surface of the nodule often degenerates after re- 
peated desquamation — a condition which, if preceded by sexual 
intercourse, will lead the patient to believe that he has been 
infected anew. The consecutive ulceration may begin in the 
center as well as at the upper surface of the nodule, or eccen- 
trically, and may remain superficial or attack the deeper layers. 
It may originate at several points simultaneously and progress 
rapidly, and thus resemble phagedena — a phagedena that con- 
sumes the entire nodule without attacking the parts around it. 
This kind of phagedena vanishes all the more quickly when 
the ulcer is not interfered with by caustics or irritating reme- 
dies. 

Sometimes, though rarely, the primary sclerosis undergoes 
a peculiar softening. The center of the nodule liquefies, form- 
ing a yellowish, purulent, or ichorous fluid, which, as in an ab- 
scess, gradually escapes outwardly through several small open- 
ings. The remaining walls of the abscesses that form in the 
primary induration disappear by absorption. A second scle- 
rotic nodule occasionally originates in the immediate vicinity 
of the first one, although recurrence of the infection has not 
taken place. 

The size and extent of the induration possess no prognostic 
significance respecting the benign or malignant character of 
the syphilis. Small and recent indurations usually are more 
amenable to treatment than those which are large and old. 

On the appearance of the eruptive fever and of the cuta- 
neous syphilide the induration generally becomes small, and 
soon disappears entirely, leaving behind a copper-colored spot, 
which, as a prognostic sign, is of no less importance than the 
induration itself. So long as this discolored spot is not en- 
tirely absorbed, the syphilitic diathesis is not cured, even 
though all the other symptoms of the skin and mucous mem- 



158 PATHOLOGY AND TREATMENT OF SYPHILIS. 

brane produced by the syphilis have vanished, or perhaps have 
not yet appeared at all, because the induration has been treated 
with mercury from its very inception. 

According to our experience, it sometimes happens that an 
induration that has well-nigh disappeared, grows again after 
a longer or shorter period, and attains its former proportions 
(chancre redux), a condition that has been described as repul- 
lulation of the sclerotic node. This is, in so far, of prognostic 
importance, as it proves the obstinacy of the disease, and may 
be considered a prodrome of the speedy eruption of a syphilide. 

We have seen indurations last three months, even when 
the patient was treated with mercury from their very incep- 
tion. Very often they last eight or nine months, and even 
longer. 

With regard to the differential diagnosis, syphilitic initial 
sclerosis may easily be mistaken for epithelioma. The micro- 
scopic examination, to be sure, will furnish satisfactory evi- 
dence of the nature of the morbid alteration ; but the expe- 
rienced clinical physician will also be able to exclude syphilitic 
induration from the continuous disintegration of the carcinom- 
atous infiltration, and from the absence of the solitary, degen- 
erating, peculiar, rosy-red, velvety sclerotic ulcer. The dif- 
ferential data between soft chancre and a Hunterian indurated 
chancre have already been described. 

"We have repeatedly seen in children, who had been cir- 
cumcised according to the orthodox Hebrew rite, a distinct 
indurated node undergoing disintegration, situated in that part 
of the foreskin which remained, and in the glans penis, with 
coexisting hyperplastic enlarged lymphatic inguinal glands, that 
sometimes suppurated. Yet the children never suffered from 
secondary syphilis, having been kept under observation long 
enough to settle that point. Hence it seems that this kind of 
induration must be ascribed to the unskillful manner in which 
the operation, especially the laceration of the mucous mem- 
brane of the prepuce, was performed. 

Unicity of the Syphilitic Infection. 

Since other specific diseases, such as scarlatina, measles, etc., 
seldom occurred more than once in the same person, it was 



SYPHILIS. 159 

supposed that this might also be true of syphilis. And, in 
fact, instances of persons having syphilis twice are very rare 
exceptions. Experiments undertaken for the purpose of con- 
finning this belief have proved that inoculations of persons 
with syphilitic virus who are still under the influence of the 
syphilitic diathesis produce no indurated chancres. From 
the results of these experiments Ricord was able to formulate 
the dogma of the unicity of syphilis (iincite de la syphilis) — 
i. e., any one who had or has syphilis, or, what amounts to the 
same thing, has had a Hunterian indurated chancre, never can 
get it again ; more correctly speaking, never can be infected 
again by syphilis. Ricord explained this law, which he an- 
nounced, by the assertion that the syphilitic poisoning, when 
once produced, lasts forever, and our treatment is only able 
to cause the manifestations of the disease, but not the disease 
itself, to disappear. 

This dogma of the unicity of syphilis is not, however, so 
invariably true as Ricord claims. H. Zeissl and other physi- 
cians have had repeated opportunities of observing reinfection 
in one and the same person. The reinfection with syphilis of 
a person who has had the disease proves that he was totally 
cured of his first attack. According to Diday, three important 
corollaries may be deduced from this law, namely : 

(a.) Syphilis can be cured radically. 

(b.) The length of time necessary for a radical cure of 
syphilis is at least twenty-two months. 

(<?.) The best proof that syphilis can be cured radically is 
the possibility of reinfection. 

The treatment of syphilitic reinfection is the same as that 
of primary infection. 

Affections of the Lymphatic System occasioned by Beginning 

Syphilis. 

On examining the parts of the body in the vicinity of a 
Hunterian indurated chancre, there will generally be found 
one or more lymphatic glands which are swollen and dense, 
and have the same hardness as the chancre. This glandular 
swelling is, it is true, rather painful during the early days of 
its existence, but, after a while, it usually becomes less sensitive 



160 PATHOLOGY AND TREATMENT OF SYPHILIS. 

when touched. On account of this painless condition, it is de- 
scribed as an indolent swelling of the lymphatic glands, or 
bubo. The enlargement of the affected glands takes place 
without any marked reaction, or the least febrile movement. 
At first the implicated glands are but slightly swollen, and 
quite movable ; but the more they swell, the more they become 
adherent to the subjacent tissues. As a rule, the skin over 
them remains unaltered, and for a long while afterward may 
be pinched up in folds. Several adjacent glands are usually 
swollen ; still, they remain isolated from each other, and only 
exceptionally do they coalesce into one common tumor. 

These indolent buboes usually do not form until the initial 
lesion of syphilis is already in a state of disintegration. Fi- 
nally, if we take into consideration the fact that indolent buboes 
are almost always found on the parts of the body nearest the 
site of the infection, we are justified in maintaining that, from 
a genetic point of view, they are buboes of absorption, and not 
of constitutional origin. Auspitz asserts that the propagation 
of the contagium of syphilis to the blood, from its point of en- 
trance into the system, does not take place through the lym- 
phatic vessels, and thus cause all the lymphatic glands of the 
body gradually to swell up as the poison progresses, but that 
the indolent inguinal buboes only indicate the local' absorption 
by the glands lying adjacent to the primary lesion, while the 
direct absorption of the poison from its place of entrance most 
probably is brought about through the blood-vessels. The 
general swelling of the glands which occurs in syphilis is 
simply an evidence of the blood-poisoning that is already 
present. 

The pathological alterations of the glands under considera- 
tion are the result of hyperplastic enlargement of all those 
elements which constitute the affected glands, not excepting 
even the glandular capsule, which is more or less thickened. 
In the further course of the disease the glands undergo fatty 
or amyloid degeneration. 

The indolent glandular swellings sometimes are round and 
then again oval, and, as a rule, become as large as a hazel-nut or 
walnut. In scrofulous, tuberculous, and weakly persons, they 
quickly attain, as a general thing, an enormous size,, attended 



SYPHILIS. 161 

by more or less marked inflammatory phenomena, and occa- 
sionally constitute, when they are close to each other, tumors 
as big as a man's fist. These enormous glandular swellings 
have long been designated as strumous buboes, because the word 
" strumous " signifies the same as scrofula. Strumous buboes 
usually present an uneven, lobulated appearance, and are con- 
stricted in various places. 

As has been mentioned above, the glands adjacent to the 
place of infection are always affected first, in consequence of 
the absorption of the syphilitic virus ; still, the cubital gland, 
in exceptional instances, in chancres on the fingers, is over- 
leaped, and the axillary or jugular glands on the corresponding 
side become involved. As most of the syphilitic infections 
take place on the genital organs, we consequently find that the 
glandular disease that invariably follows occurs in the inguinal 
and femoral region. As a rule, only the superficial inguinal 
and femoral glands swell up, the deeper ones becoming in- 
volved when constitutional complications are present, such as 
scrofula, tuberculosis, or rachitis, or through local purulent 
imbibition. Several inguinal or femoral lymphatic glands are 
generally affected. 

Indolent glandular indurations, in consequence of syphi- 
litic infection on the genital organs, mostly occur on the side 
of the body that the Hunterian chancre is situated on ; excep- 
tionally, however, the glandular induration is met with on the 
opposite side, and in primary lesions situated on the median 
line of the genital organs, such as the frsenum or posterior 
commissure of the vulva, the glands in both groins will become 
indurated. 

Indolent buboes often remain stationaryfor three or four 
months, notwithstanding the anti-syphilitic treatment employed; 
after many years they diminish, and disappear by absorption. 
Sometimes they undergo calcareous degeneration. Resolution 
takes place by the process of fatty degeneration. 

Syphilitic buboes seldom undergo suppuration ; and, when 
they do, it is in consequence of constitutional or local compli- 
cations. Scrofula and tuberculosis are the chief causes that 
bring about softening or caseous degeneration of the indolent, 
hypertrophied lymphatic glands. Strumous buboes, however, 
11 



162 PATHOLOGY AND TREATMENT OF SYPHILIS. 

differ vastly in their course from the small ordinary indolent 
bnboes. The movable skin, covering strumous lymphatic 
glands, soon becomes adherent to the swelling beneath it, 
gradually turns red, and even slight pressure causes pain. But 
notwithstanding the palpable inflammatory phenomena, it re- 
quires an extremely long while for deep softening to ensue. 
The same is true of resolution, which the best directed meas- 
ures are slow to bring about. Finally, a few solitary spots in 
the swelling, as big as a hazel-nut or walnut, become spongy 
and fluctuate. Nevertheless, when an incision is made, only a 
small quantity of glutinous fluid and considerable bloody serum 
escape. A premature incision into one of these buboes will 
produce a rapid, but only partial, disorganization of the swell- 
ings. However, only the subcutaneous and the glandular in- 
termediary cellular tissue is destroyed, while the hyperplastic 
enlarged glands themselves remain intact. Hence, one or 
more tortuous fistulse form in the entire region of the glandu- 
lar swelling, beneath the skin or between the lobes of the 
glands. If the undermined skin is divided with a knife, a 
layer of new connective tissue often forms on the lips of the 
wound, between which the new tissue frequently extends, at a 
later period, like bridges and arches. The adventitious tissue 
usually is destroyed, and involves in molecular disintegration the 
subjacent cellular tissue that exists between the swollen glands, 
thereby vastly enlarging the ulcer. It acquires a yellowish, 
lardaceous coating, and at the bottom the glands, hypertrophied 
and increased to the size of walnuts, and partially deprived of 
their capsules, are seen as if dissected out with a knife. As a 
result of the burrowing, and also of the imbibition of the pus, the 
diseased lymphatic glands and other portions of connective tissue 
become involved in the morbid process in different directions ; 
new straight or tortuous inflammatory foci start up on the pro- 
longations of the adventitious connective tissue, which likewise 
soon deliquesce through molecular disorganization, causing 
new fistulous passages. Along the course of the fistula the 
connective tissue becomes indurated, and the tract becomes 
lined with a pyogenic membrane, which, however, does not 
secrete pus, the discharge being at the most a fluid that con- 
tains molecular disorganized matter. The pus and the ichor 



SYPHILIS. 163 

may burrow in these fistulous passages ; and, in case a timely 
exit is not provided, new inflammatory foci will start. 

Under the local complications which softening of indolent 
buboes may occasion, even in persons with good constitutions, 
we understand suppurating foci situated on places which, by 
means of the lymphatic vessels, are intimately connected with 
the indolent glandular swellings. To this category belong 
moist, ulcerating papules, syphilitic and non-syphilitic pus- 
tular eruptions, specific and non-specific ulcers, syphilitic 
and non- syphilitic panaritioe [paronychias], but, above all, 
chancrous ulcers, and sometimes blennorrhagia of the genital 
organs. Now, if the pus originating from one of these suppu- 
rating processes finds its way, through the action of the lym- 
phatic vessels, into the indolent swollen gland, all the inflam- 
matory phenomena that occur in an acute bubo of absorption 
manifest themselves in the swelling that hitherto had remained 
dormant. 

Inoculations made with the purulent contents of indolent 
buboes on persons affected with them, as also on syphilitic pa- 
tients generally, are of importance only in so far as they show 
that, even in those cases in which softening was not caused by 
complicating chancroid ulcers, any kind of pus, as we have 
already shown, when inoculated, will produce positive results. 

The prognosis of indurated buboes which accompany Hun- 
terian chancres must be considered from a double standpoint : 
first, as regards their significance for the general system ; and, 
secondly, as regards the local morbid alterations that are liable 
to occur in the affected glands and their immediate surroundings. 

The Hunterian primary lesion does not acquire its full pa- 
thognomonic and prognostic value till the indurated glands ap- 
pear ; i. e., we are not justified in considering a circumscribed 
induration of the tissues as a result of syphilitic infection and 
in prognosticating the speedy appearance in the affected person 
of other syphilitic lesions in other tissues of the body, till the 
swelling of the glands has ensued. 

Now, as regards the local significance, most of the indu- 
rated buboes in persons with good constitutions, under an ap- 
propriate treatment, are made to disappear in the course of 
four or five months, either by absorption or calcification. It 



164 PATHOLOGY AND TREATMENT OF SYPHILIS. 

is totally different in the case of indolent strumous buboes. 
They are the unfortunate products of a complication that is of 
the utmost importance for the future of the patient — name- 
ly, of syphilis with scrofula or tuberculosis — two diatheses that 
are liable to be kindled, and which, if developed by syphilis, 
exercise a most pernicious influence over the development and 
resolution of the syphilitic morbid lesions. The tedious char- 
acter of scrofula and of tuberculosis is soon manifest from the 
tedious course of the strumous bubo. Strumous buboes usu- 
ally outlast all the other early phenomena of syphilis. Under 
favorable contingencies they require five or six months for reso- 
lution, which, however, only partially takes place; a large 
portion of the affected glands undergoes calcification. Still, 
even fluctuating strumous buboes may undergo resolution, 
provided suppuration was not occasioned by the absorption of 
chancroid virus. These kinds of buboes often burst ; a small 
quantity of pus mixed with bloody serum escapes, and the 
remainder of the tumor soon becomes smaller. The future 
destiny of strumous buboes, when they are prematurely opened, 
assumes a far more unfavorable course. In this case, deep, 
penetrating destruction of the tissues may follow. In inguinal 
and femoral glandular buboes fistulse may originate, which may 
extend from Poupart's ligament downward to the apex of the 
trigonum inguinale and upward as far as the navel. The pus 
may escape into the inguinal canal, and thence into the abdo- 
men, or, following the spermatic cord downward, accumulate 
in the scrotum ; or, after penetrating the femoral fascia and 
the sheath of the femoral vessels, reach the knee-joint. Maras- 
mus, tabes, fatal peritonitis, and pysemia are frequent results of 
this condition. It is even possible for gangrene to supervene, 
and deep arteries, that are difficult to ligate, like the epigastric 
or iliac, become eroded, causing haemorrhage that terminates in 
death. The cicatrization of strumous, inguinal buboes, too, 
may afflict the patient with the most serious permanent annoy- 
ance, by the formation of a cord-like cicatrix that extends from 
the groin down along the anterior surface of the thigh, or 
upward upon the abdomen. These cicatrices, in time, may 
contract to such a degree as to prevent the patient from stand- 
ing upright. 



SYPHILIS. 165 

Induration and Hypertrophy of the Peripheral Lymphatic Ves- 
sels in consequence of Syphilitic Infection. 

In some cases it is possible to demonstrate the manner in 
which the primary affection of the lymphatic glands by the 
syphilitic virus was brought about, by a pathological alteration 
of those lymphatic vessels which run from the Hunterian 
chancre to the indolent glands. Without any phlegmonous phe- 
nomena, and in the most passive manner, an inflammatory pro- 
cess develops in the affected lymphatic vessels, in consequence 
of which they become like cords, hard and movable under 
the skin, painless, and of the thickness of a raven's quill or 
goose-quill. The hypertrophy of the cord-like lymphatic ves- 
sel is not always uniform throughout its entire extent ; many 
nodular swellings of the size of a millet-seed up to that of a 
hazel-nut form at various places in the course of the lymph- 
current. The skin covering the lymphatic cord is usually un- 
altered ; but after the nodular swellings have lasted for many 
weeks a slight furfuraceous desquamation and redness of the 
skin over them are observed. On the appearance of these phe- 
nomena, a syphilitic eruption generally supervenes. 

The indolent induration of the lymphatic vessels originates 
at the same time with the induration of the lymphatic glands 
that ultimately become indolent, and it has the same pathogno- 
monic significance. The same morbid alteration which takes 
place in the cells of the gland occurs in the lumen of the af- 
fected lymphatic vessel. In most cases, however, the swelling 
of the glands, in coexisting induration of the lymphatic ves- 
sel, is not very pronounced. The infarction of the lymphatic 
vessel always disappears by resolution. If many nodules exist, 
those situated at a distance from the place of infection, and of 
the most recent formation, disappear first. We have rarely 
seen suppuration and breaking down of this kind of lymphatic 
vessels. 

The affection of the lymphatic vessels, just described, oc- 
curs with the greatest frequency on the dorsum of the penis ; 
sometimes, however, on the lateral surfaces of this organ, as 
also on the prepuce and near the frgenum ; but at the latter 
place the cords are much shorter. We have never observed 



166 PATHOLOGY AND TREATMENT OF SYPHILIS. 

this morbid lesion on other parts of the body ; in females, it 
occurs in exceptional instances only. 

The Syphilitic Diathesis. 

Although one is justified in assuming that after the Hun- 
terian induration has taken place, and the indolent buboes 
have appeared, the general toxaemia is established, since no in- 
duration can be produced anew on the persons afflicted with 
the local lesions mentioned by inoculating them with syphilitic 
virus ; nevertheless, patients suffering from the early phenom- 
ena of syphilis are apparently in good health for a time, and 
we are totally unable to discover the least sign of the consecu- 
tive phenomena of the disease that are destined to develop 
in the various tissues of the body. This period of quiescence 
in the development of the constitutional phenomena is de- 
scribed as the second period of incubation. In order to explain 
this interval that takes place between the occurrence of the in- 
duration and of the indolent swelling of the glands, on the one 
hand, and the outbreak of the remainder of the constitutional 
phenomena, on the other hand, it is assumed that the syphilitic 
virus is dormant for a while in the system, and then becomes 
active again. This hypothesis is supported in a measure by 
the fact that frequently, even in the latter periods of constitu- 
tional syphilis, a temporary period of apparent extinction of 
the disease occurs {latency of syphilis). 

It is our opinion that in syphilis the disease of the lym- 
phatic system, at any rate, is of prime importance, and that 
the syphilitic virus is conveyed to the blood by the lymphatic 
vessels ; and that by the constant mutual interchange that 
takes place between the blood and the lymph the syphilitic 
virus permanently changes specifically the entire quantity of 
the blood. Our senses, however, are not capable of perceiving 
the morbid alteration of the blood produced by the syphilitic 
virus. With the same degree of justice that we assume the 
diseased condition of the lymph from the morbid alterations 
of the lymphatic vessels and glands without being able to prove 
the morbid alterations of the lymph, so do we feel justified in 
assuming the diseased condition of the blood from the morbid 
state of the rest of the tissues of the body. And just as the 



SYPHILIS. 167 

lymph must be diseased before the affection of the lymphatic 
vessels and glands appears, so must the blood be morbidly 
changed before any sign perceptible to our senses will indicate 
its diseased condition in the various tissues of the body. 

These pathological disturbances of the composition of the 
blood that are un demonstrable, being only inferable from the 
results, have been designated by the name of syphilitic diath- 
esis — a condition that is intended to fill up the gap between 
the infection that had taken place and the pronounced syphi- 
litic dyscrasia. 

Pathological Alterations of the Blood of Syphilitic Persons. 

After the Hunterian indurated lesion has lasted for eight 
or ten weeks, those phenomena gradually appear which incon- 
testably prove that certain morbid alterations of the blood have 
taken place. The skin of the patient loses its fresh, healthy, 
rosy color, and gradually acquires a waxy, sallow, chlorotic hue. 
At the same time a general emaciation ensues in many cases. 
So far, neither chemistry nor the microscope has succeeded in 
finding any pathognomonic products in the blood of syphilitic 
patients. 

We believe that although the syphilitic blood-disease begins 
with the absorption of the syphilitic virus, still it is just as lit- 
tle possible in the early days of the disease to prove the altera- 
tion of the blood as in most other infectious diseases. The 
macroscopical alterations on the syphilitic patient compel us 
to assume that the nutritive element, at least the albumen of 
the blood, has suffered some kind of change. The altered 
blood, on the one hand, then exercises an extraordinary amount 
of irritation upon the lymphatic glands, whereby they become 
hypertrophied ; on the other hand, by the disease of the lym- 
phatic glands, a retroactive effect upon the blood must also take 
place, either because the abnormal increase of cell-life of the 
glands causes larger numbers of white blood-corpuscles to 
enter the blood, or because after ischgemia of the lymphatic 
glands has ensued, the formation of blood-corpuscles is entirely 
arrested. But neither leucaemia nor oligemia and chloraemia, 
are the causes of the original blood-disease — they are simply 
its effects. 



168 PATHOLOGY AND TREATMENT OF SYPHILIS. 

[Quite recently Lustgarten and Doutrelepont have found, 
in the morbid product of the syphilitic diseases and in the 
discharges, bacilli which in form resemble tubercle bacilli, but 
are distinguished from them by the staining. The bacilli are 
mostly inclosed in cells, from two to eight in one cell ; very 
few of the latter are found in the center of a syphilitic exuda- 
tion, but in larger numbers at its borders, and in the adjacent 
apparently still normal tissues. 

The bacilli are always found in the initial syphilitic lesion, 
in the papules, in the gumma nodes, and in the discharge from 
a syphilitic chancre and from the papules. This fact, taken 
in connection with the negative results obtained by similar re- 
searches, made into the most varying morbid products, renders 
it highly probable that these bacilli actually constitute the syphi- 
litic poison. This probability becomes still greater since we 
have learned that bacilli are likewise the contagium of infec- 
tious diseases that are analogous to syphilis — lepra, tuberculo- 
sis, etc. — though this will not be irrefutably established till we 
are able to generate the bacilli outside of the human body, and 
to produce syphilis by inoculations with a bacilli product ob- 
tained by cultivation.] 

Eruptive Fever of Syphilis. 

The first eruption of general syphilis is usually preceded 
by febrile movement, which is not unlike that occurring in 
catarrhal or rheumatic affections. The patients are hot, rest- 
less, and sleepless, and feel uncomfortable, tired, and suffer 
from loss of appetite. In some cases, a ravenous appetite comes 
on. The expression of the face becomes dull, the skin pale, 
the eyes sunken and tired. At the same time the individuals 
are tortured by vague rheumatic, intermitting pains, which 
now afflict the head, next the shoulders, and then again some 
of the joints and limbs of the body, or localized neuralgias, for 
instance, of the infra-orbital nerve, are present. In many pa- 
tients a blowing heart-murmur is audible. The pulse often 
reaches one hundred and ten per minute, and some increase of 
temperature is also noticeable. The patients suffer from night- 
sweats, and their urine deposits a heavy sediment of uric-acid 
salts and urerythrin. 



SYPHILIS. 169 

Tlie eruptive fever subsides on the outbreak of the morbid 
phenomena in the various organs and on different parts of the 
body, but sometimes it returns again in the course of the af- 
fection, when sequelae or relapses ensue. The eruptive fever 
usually attains its acme in twenty-four or forty-eight hours ; 
then it generally remits, as in acute exanthemata. In regard to 
the influence of the remedies that have been resorted to in a 
given case, upon the increase of the temperature, it may be 
said the inunction of blue ointment usually causes a slight 
increase of the temperature, but later on in the disease it is 
often followed by abnormal diminution of the temperature. 
The treatment with the preparations of iodine at first does 
not seem to have any marked effect upon the temperature ; 
later on, it causes an increase, but soon after using them the 
temperature returns to the normal. 

Time of Eruption of General Syphilis. 

According to our experience, the eruption of secondary 
phenomena never takes place before the eighth week after 
infection. Remedial measures may postpone the outbreak of 
syphilis, but they can not prevent it ; we possess no remedy 
with which we can eradicate the disease, and, still less, annihi- 
late it, in the first few weeks of its existence. On the other 
hand, injurious influences, such as violent mental excitement, 
excesses in Baccho et Venere, forced marches, traveling at 
night, etc., may hasten the outbreak of the secondary phe- 
nomena. 

Localization of the Syphilitic Foci. 

All the tissues of the human body may become diseased by 
syphilis ; still, the morbid process seems to have a preference 
to become localized upon the common integument. ISText in 
frequency, certain parts of the mucous membrane — for instance, 
the nares, fauces, mouth, larynx, oesophagus, rectum, vagina, 
uterus, urethra, etc. ; next the periosteum, the endosteum, and 
the bones themselves (especially some flat and a few long tubu- 
lar bones), the perichondrium, and the cartilage of certain or- 
gans, the septum nares, and larynx, for instance, and certain 
serous membranes, the perimysium and the iris — are attacked. 



170 PATHOLOGY AND TREATMENT OF SYPHILIS. 

Of the fibrous membranes, the albiiginea testis and the sclerotic 
coat of the eye are the only ones that are affected. The sub- 
mucous and subcutaneous tissues are often attacked ; the liver, 
spleen, heart, kidneys, lungs, brains, and certain nerves, the 
blood-vessels and bowels, are less frequently diseased. 

The Cachexia produced by Syphilis. 

If syphilis has once engendered certain morbid alterations 
in some of the organs that play an important part in the econ- 
omy, the constitution of the patient is sure to suffer from a 
cachexia that will completely exhaust him, and the disease will 
terminate in death. This is especially the case when, in con- 
sequence of amyloid degeneration of the kidneys, albuminuria 
or hsematuria is produced. Certain conditions of the individ- 
ual — bad living, complications with other diseases, such as tu- 
berculosis, gout, scurvy, improper treatment, etc. — are likely to 
hasten such an unfortunate termination. 

Combinations of Syphilis. 

Acute diseases exercise a remarkable degree of influence 
over syphilis, especially over the early phases of the disease. 
The muco-papular syphilide of the skin, and of the mucous 
membrane, quickly disappears on the occurrence of an acute 
affection, but returns as soon as the latter subsides. On the 
other hand, the dry and ulcerative forms of skin lesions, mu- 
cous patches, plaques muqueuses, syphilitic diseases of the 
bones, are but little affected by acute maladies. 

Chronic diseases may not only coexist with syphilis, but 
will accelerate its course. This is especially the case with the 
consumptive affections, such as tuberculosis, scurvy, etc. A 
combination of gout and syphilis renders both morbid pro- 
cesses obstinate to treatment. Syphilis exercises a most inju- 
rious effect over pregnancy, frequently resulting in abortions 
and miscarriages. On the other hand, pregnancy retards the 
retrograde development of syphilis, the anti-syphilitic remedies 
being hindered in their action by the process of gestation. 

In regard to the influence of syphilis upon the course of 
a wound, clean cuts heal in syphilitic persons as rapidly as 



SYPHILIS. 171 

in the non-syphilitic. But if a fresh syphilitic scar is cut 
into, it will occasionally be transformed into an ulcer. The 
union of fractures is sometimes retarded by the syphilitic di- 
athesis in syphilitic persons. Mechanical or chemical irritations 
are liable to produce, on the irritated places, inflammatory prod- 
ucts analogous to the phase of luetic lesions from which the 
patients happen to be suffering at the time. Cauterizations 
performed on persons afflicted with a recent or latent form 
of the disease do not furnish such results as would justify one 
in inferring from their appearance the character of the syphi- 
lis present (cauterisatio provocatoria of Tarnowsky). 

Succession and Phases of Syphilitic Affections. 

Not only the manner of succession in which syphilis attacks 
the different tissues, but the local morbid phenomena and their 
metamorphoses display a certain degree of regularity. First 
of all, the lymphatic glandular system, the common integu- 
ment, with its appendages, and the mucous membrane, become 
diseased. The affection of the periosteum, of the bones, of the 
subcutaneous and submucous connective tissue, follows later. 
The affections of the viscera belong to this category. In con- 
sideration of this well-nigh constant succession of attacks, Ei- 
cord divided them into three groups, and designated them as 
primary, secondary, and tertiary syphilis. In the primary 
stage he placed the Hunterian sclerosis and glandular indolent 
swelling ; in the secondary, the disease of the upper layer of 
the general skin and the mucous membranes ; in the tertiary, 
the affection of the subcutaneous and submucous connective 
tissues, the bones, the serous and fibrous membranes, and the 
parenchymatous organs. 

But no such distinct division as was made by Eicord really 
exists. Thus, there are often seen syphilitic affections of the 
bones in the early period of the disease, and, conversely, ozsena 
syphilitica frequently occurs in connection with those erup- 
tions of the skin which Eicord places among the secondary 
phenomena. It seems to us that the classification adopted by 
H. Zeissl, namely, the stage of moist papules, or condylomata, 
and the stage of gummatous adventitious growths, is much 
more correct, because the appearance of the first gummatous 



172 PATHOLOGY AND TREATMENT OF SYPHILIS. 

node upon the skin, or in any of the visceral organs, almost 
excludes the presence of moist papules. The morbid processes 
of the condylomatous stage may be regarded as lesions of irri- 
tation, those of the gummatous stage as new growths. The 
first group embraces the affections of the lymphatic system, of 
the skin and its appendages, of some parts of the mucous mem- 
branes, and of the iris. The second group includes the dis- 
eases of the subcutaneous and submucous cellular tissues, of 
the fibrous membranes, of the bones and cartilage, of the mus- 
cles and viscera. 

Development, Course, and Duration of Constitutional Syphilis, 
and its Mortality. 

The development and dissemination of syphilis do not go 
on steadily and uninterruptedly; apparent recoveries (stages 
of latency) occur periodically, and are followed by new erup- 
tions, which may be more severe even than the preceding 
ones. The intervals of apparent recovery may last many months, 
even many years. On carefully examining such a patient, 
traces of latent syphilis, such as swelling of the lymphatic 
glands, opacity and hypertrophy of the epithelial cells of some 
parts of the mucous membrane, discolored cicatrices, hypertro- 
phies or nodes on the bones, etc., will always be found. The 
slow or rapid succession, as also the speedy or tardy develop- 
ment and resolution of some of the morbid lesions, varies ex- 
ceedingly, and depends chiefly upon the congenital or acquired 
individual peculiarities of the constitution, and upon the age 
of the patient ; sometimes, however, also upon various acci- 
dental causes and influences. In syphilis, the law of partium 
minoris resistentiw is seen everywhere exemplified. The phe- 
nomena of the first stage, as a rale, display a certain degree of 
activity, while the symptoms of inveterate syphilis (gumma- 
tous phase) run a tedious course. In some cases the different 
phases of the disease follow each other rapidly and violently 
(syphilis galopant), while in others, months, and even years 
pass before a new eruption follows, or more serious effects of 
an almost forgotten disease appear. In the first phases of 
syphilis the dry eruptions of the skin usually disappear by 
resolution ; in the later periods, however, ulcers form. 



SYPHILIS. 173 

The duration, like the course of syphilis, varies exceed- 
ingly, according to the individual peculiarities, the age, and 
the conduct of the patient, and the various complications that 
may occur. If the natural course of the disease is not inter- 
fered with by therapeutical measures, a complete spontaneous 
cure may take place at the end of a certain length of time ; 
but, conversely, in patients who undergo no treatment, the 
most serious forms of syphilis may develop. Treatment exer- 
cises a most important influence over the course and duration 
of the disease. Syphilitic patients who are mercurialized very 
early, especially before general phenomena have appeared, are 
oftener attacked by grave lesions of syphilis (cerebral and vis- 
ceral), and they are oftener subject to relapses than those who, 
for a long time, were not treated at all, or first with iodine, 
and later on with mercury. A cure of the disease may indeed 
be brought about in any of its stages ; the most rapid and 
permanent is achieved in those most recently attacked. In 
the most favorable cases, to be sure the rarest, a cure may be 
accomplished in from three to four months ; in most instances, 
however, it takes two, three, or more years. Under unfavor- 
able conditions and unsuitable treatment, the disease, now im- 
proving, and then again becoming aggravated, will drag along 
many years till finally some serious lesions of the tissues, or 
disturbance in the functions of important organs, ensue, re- 
sulting in paralysis and chronic invalidism that terminate in 
death. 

Syphilis itself rarely causes death ; and, when this hap- 
pens, it is generally in consequence of gangrene, profuse hem- 
orrhage from arterial branches that are difficult Lo ligate, or 
necrosis of the bones of the skull. In some cases, suffocation, 
in consequence of hsemorrhage into Morgagni's cavity of the 
larynx, or oedema of the vocal cords (laryngostenosis syphi- 
litica) puts a sudden end to the patient's existence ; while 
in equally rare cases the patients succumb to albuminuria 
(Bright's disease), syphilitic affections of the liver, of the nerv- 
ous centers, of the cardiac muscle, to marasmus, or, finally, to 
tuberculosis generated by syphilis, or an improperly managed 
mercurial treatment.. 



174 PATHOLOGY AND TREATMENT OF SYPHILIS. 

Development of Lymphatic Glandular Swellings originating in 
the course of Syphilis (Multiple Adenitis). 

In about five or six weeks after the indolent buboes have 
formed in the immediate vicinity of the primary syphilitic in- 
duration, other chains of lymphatic glands enlarge in various 
regions of the body at a distance from the indolent buboes. 
We think we are justified in offering the following physio- 
logical explanation of the syphilitic swelling of the lymphatic 
glands, viz. : The syphilitic virus is absorbed by the lymphatic 
vessels, and the first pathological sign that absorption has taken 
place is the appearance of an indolent bubo. The syphilitic con- 
tagion is not retained in this primary swollen lymphatic gland, 
but is conveyed with the lymph to other tissues and glands. 

The chains of lymphatic glands that swell up most mark- 
edly are those situated in the neck at the posterior border of 
the mastoid process and sterno-cleido-mastoid muscle, the jugu- 
lar and subclavicular, the axillary, and the remainder of the 
inguinal glands which were not primarily affected, the cubital 
and the submaxillary glands. In the syphilitic cadaver, the 
lymphatic glands situated upon the inner surface of the ster- 
num, the bronchial, the abdominal, and the pelvic glands, are 
also found greatly enlarged. 

The enlarged syphilitic glands at first are only as large as a 
pea, bean, or hazel-nut, and, as a rule, swell up without any 
inflammation, and are not sensitive ; but, like the primary in- 
dolent buboes, they may subsequently become greatly enlarged 
in consequence of scrofula or tuberculosis, and undergo sup- 
puration, in part at least, if they absorb purulent material 
from any ulcerating sore in the vicinity. 

Multiple adenitis is an almost constant attendant upon all 
the other syphilitic lesions, and generally keeps pace with 
them in their aggravation and improvement. In doubtful 
cases it is a most valuable sign regarding the nature and char- 
acter of the morbid lesions situated in other tissues of the 
body; and even in those cases in which a partial cure has 
caused the other effects of the disease to disappear, it is often 
the only evidence that the syphilitic diathesis is not entirely 
extinguished {latent syphilis). 



SYPHILIS. 175 

The syphilitic glandular hypertrophies, in persons who are 
in other respects well, never attain such large proportions as 
the scrofulous hypertrophies. The former are smooth on 
their upper surface — the latter nodular and uneven. Syphi- 
litic swellings of the glands, under favorable conditions, gradu- 
ally grow smaller and disappear, or they undergo fatty, cal- 
careous, or amyloid degeneration. Scrofulous glandular hy- 
perplasia frequently become inflamed from very slight exter- 
nal causes, and pus forms in several places. The pus becomes 
inspissated, fatty, calcareous, or degenerates into a cheesy sub- 
stance ; but in the end the tumor ruptures at several points, 
and torpid ulcers of the skin, with livid undermined edges, 
originate, which now secrete a thin, sticky, adhesive matter, 
and then again an inspissated cheesy discharge, aud heal by the 
formation of contracting, radiating cicatrices. 

Morbid Lesions of the Skin caused by Syphilis (Syphilitic 
Diseases of the Skin — Syphilides). 

Syplnlis produces on the skin the first and the most fre- 
quent morbid alterations. Alibert has included them all under 
the common name of " syphilides." The nature of the morbid 
process upon the skin, like all syphilitic forms of disease, is due 
to chronic, circumscribed inflammations and circumscribed for- 
mation of new connective tissue. Active granular and cellular 
proliferations take place at the affected places. The granules 
and cells are either reabsorbed, or they degenerate into pus- 
corpuscles, or become transformed into connective-tissue cells 
and fibers. These processes produce either dry or purulent 
eruptions. The dry eruptions are represented by the maculae, 
papules, nodules, and tubercles ; the purulent by vesicles, 
pustules, and rupia. These eruptions, however, are also pro- 
duced by the most varying morbid conditions not allied to 
syphilis. Hence, there are no eruptions that belong exclu- 
sively to syphilis ; the latter imitates all eruptions of the ordi- 
nary affections of the skin. 

The resemblance of the syphilides to the non-specific dis- 
eases of the integument, the form and the kaleidoscopic appear- 
ance of the eruptions, as also the variable degree of the meta- 
morphoses they undergo, always make the diagnosis of syphi- 



176 PATHOLOGY AND TREATMENT OF SYPHILIS. 

litic affections of the skin exceedingly difficult. The following 
signs will aid us in forming a diagnosis in specific diseases of 
the skin : 

(1) The markedly circumscribed form of some of the erup- 
tions. Even the so-called areola, when present, does not merge 
gradually into the normal skin surrounding it, but ends abruptly. 

(2) The peculiar color of some of the syphilitic eruptions. 
The red color, namely, of syphilitic maculae, papules, areolae, 
nodes, and partly also of cicatrices, is not like the fresh, rosy, 
red color of the corresponding non- syphilitic eruptions and 
scars, but is a dull, brownish-red, resembling somewhat the 
color of bacon when cut into, or of tarnished copper. This 
peculiarity is not equally marked in all stages and phases of 
the disease. The more recent a syphilide, the shorter the 
time that has elapsed since the period of infection, the sooner it 
appears, and the more superficial the eruptions — the brighter 
the red color will be ; the older the syphilide, the more slowly 
it develops, the later it appears after the infection, and the 
deeper the layers of the skin are involved in the eruptive 
process — the more marked will be its brownish or coppery 
color. After their involution, the eruptions leave a brownish 
stain of the skin, that gradually merges into blue or grayish- 
blue color. Cicatrices that form after the healing of syphi- 
litic ulcerations also present, at first, a similar brownish-red 
color ; but the older and firmer they become, the whiter they 
grow. So long as a cicatrix has this color, it is liable to break 
open anew, and the syphilitic diathesis is not cured. The 
cause of this coppery color, according to our investigations, is 
to be found in the pathological composition of the eruptions, 
and is due to a teleangiectasis (as in acne rosacea) and to a pas- 
sive stasis and transudation of the coloring-matter of the blood. 
The simple hyperemia of the cutaneous capillaries gives rise 
to the rosy color, the dilatation (more or less) of the developed 
vessels to the dark-brown or brownish-red color, while the dull 
brownish discoloration is the result of the transudation of the 
coloring-matter of the blood. In badly nourished, feeble per- 
sons, especially women, this transudation is so great as to con- 
stitute actual haemorrhage; bluish-red, small and large spots 
and swellings then originate in the depending parts of the 



SYPHILIS. 177 

body. Passive stasis and the transudation of the coloring-mat- 
ter of the blood are also promoted by a depending position, as 
is the case in the legs, etc. 

(3) The location of the syphilitic eruptions. As is well 
known, syphilitic eruptions have a predilection for certain re- 
gions of the skin — for instance, the forehead and nape of the 
neck, where the hairs cease to grow, the entire scalp, in the 
groove between the ala3 nasi and cheek, commissures of the 
lips, the navel, and anal folds ; on the common integument of 
the genital organs and their vicinity, especially the inguinal and 
genito-crural fold of both sexes ; lastly, between the toes, in 
the hollow of the hands, and soles of the feet. Again, certain 
forms of syphilide have a predilection for certain localities. 
Syphilitic cutaneous nodules are met with more frequently at 
the root of the nose, on the temples, scalp, scapular and cla- 
vicular regions, over the sternum and tibiae, while no erythem- 
atous eruptions occur on the face, back of the hands, and feet. 
Lastly, certain specific eruptions, like plants, undergo marked 
modifications in their development according to their locations. 
On the parts of the skin that are provided with an abundant 
layer of fat and large sebaceous glands, whose secretions, in 
addition, are augmented by permanent frictions — for instance, 
the anal fold — moist papules grow exuberantly ; while on those 
places where the sebaceous follicles are totally absent (the hol- 
lows of the hand and soles of the feet) the papules rise scarcely 
above the level of the skin. Indeed, the sebaceous and hair 
follicles seem to promote the development of certain erup- 
tions : thus, the impetiginous syphilitic eruptions seem to pre- 
fer the hairy part of the face and scalp. The ecthyma-like 
syphilitic pustules develop oftener on the scalp and legs than 
on any other part. 

(4) The quantity and successive forms of the specific erup- 
tions. The first eruption that appears after infection consists 
of numerous but scattered inflammatory spots. The longer 
the time that has elapsed since infection, the more pronounced 
the inflammatory foci will be, and the more deeply will they 
penetrate the skin, but the less numerous will they be and ag- 
gregate in certain places, seemingly preferring to form circles 
and curves. 

12 



178 PATHOLOGY AND TREATMENT OF SYPHILIS. 

(5) The polymorphous form of the syphilitic eruption. 
The simultaneous occurrence of maculae, papules, and pustules 
of various kinds, which, owing to the protracted character of 
syphilis, may already be undergoing resolution in some places, 
while new ones are developing in others, occasions the most 
dissimilar modifications in the eruptions on the different parts 
of the body, though identical in their fundamental form. This 
gives the syphilitic diseases of the skin such an unusual poly- 
morphous picture that this symptom constitutes one of the 
most important aids in the differential diagnosis from the 
analogous non-specific diseases of the skin. 

(6) The construction of the scales and crusts of the syphi- 
litic eruptions. Specific eruptions never generate such thick 
scales as non-specific eruptions, and their color is never as 
bright and silvery as is the case, for instance, in psoriasis vul- 
garis, being more of a dirty-yellowish or grayish- white color 
(psoriasis syphilitica), {nigricans of Cazenave). The scales of 
syphilitic papules consist of the cast-off epidermal covering — in 
other words, of old, dead scarf-skin — while the scales of psoria- 
sis vulgaris consist of recent though diseased epidermal cells. 
The dark color is due to the pigment, which, as we have al- 
ready stated, the syphilitic inflammatory process deposits in 
large quantities. 

On the other hand, specific pustules produce thicker crusts 
than the non-specific pustules of corresponding dimensions. 
This is readily explained by the extremely tedious course of 
the syphilitic eruptions. By the prolonged suppuration, not 
only a greater quantity of material for the formation of crusts 
is generated, but the crusts that have already formed con- 
stantly absorb pus from the suppuration that goes on beneath 
them, and they grow more succulent and larger. Non-syphi- 
litic pustular eruptions develop more rapidly, and dry up com- 
pletely into a scab. Hence, in the latter the scabs shrink up 
more and adhere more firmly to their bases, while the crusts of 
syphilitic eruptions swim as it were upon the pus beneath 
them. By adhering a long time to the skin, the soft syphilitic 
crusts become dirty from particles of dust, etc., that accumu- 
late upon them. 

(T) The peculiar form of the syphilitic ulcer. As a pecul- 



SYPHILIS. 179 

iarity of the ulcer produced by constitutional syphilis, the kid- 
ney or horseshoe form is spoken of — i. e., it presents a concave 
surface at one place which is already healing, and a convex 
surface at another that still ulcerates. This form of ulcera- 
tion is not met with in all sores produced by secondary syphi- 
lis ; and, moreover, it occurs even in ulcers of non-syphilitic 
origin — for instance, lupus scrophulosorum. It is met with 
most frequently in the aggregating nodular syphilides (falsely 
called lupus syphilitica), in secondary ulcers preceded by rupia 
and ecthyma pustules, and in instances of new ulcerations re- 
sulting from the reopening of cicatrized sores. 

(8) The itching of the skin caused by syphilis. It is as- 
serted by some writers that the syphilides cause neither itching 
nor pain. This negative characteristic, however, does not prop- 
erly belong to all the syphilides. The moist papules on the 
fundament and near the genital organs give rise to severe itch- 
ing that causes violent scratching, and when they become ulcer- 
ated, for instance, around the anus or between the toes, are in- 
tensely painful. Papular and nodular sj^hilides in the stage 
of desquamation, especially those on the scalp and in the beard, 
that form crusts, occasion a marked degree of itching. 

(9) The peculiar odor of the exhalation and transpiration 
ascribed to syphilitic patients by some writers is not produced 
by syphilis, per se, but by the decomposition and putrefaction 
of the discharges from the moist papules, the sebum, the per- 
spiration, and the pus from numerous pustules, or the ichor 
from skin and osseous ulcers, or by a stomatitis mercurialis. 

All of the above-mentioned morphological peculiarities be- 
ing only of relative diagnostic value, the physician, in order 
to make a positive diagnosis, will have to take into considera- 
tion all the morbid lesions that occur in other tissue's and or- 
gans simultaneously with the skin-diseases. These coexisting 
phenomena or concomitantia of syphilitic disease of the skin are 
hyperplastic enlargement of the lymphatic glands, the falling 
out of the hair (alopecia), affections of the nails, of the mucous 
membrane, of the bones, of the iris, etc. We must here em- 
phasize the proposition that the physician should not be con- 
tent with making a diagnosis of syphilis from one symptom 
only, but from the sum total of all the symptoms present. 



180 PATHOLOGY AND TREATMENT OF SYPHILIS. 

Definition and Classification of Syphilitic Skin-Diseases. 

Assuming, like Biett and Bassereau, according to "Willan's 
principles, the elementary form of eruptions as a basis for 
classification, we divide the syphilides into the following forms : 

(1) The erythematous form : 

(a) Erythema maculosum. 

(b) Erythema elevatum or papulatum. 

(2) The papular form : 

(a) Syphilis papulosa lenticularis. 

(b) Syphilis papulosa miliaris. 

(c) Psoriasis palmaris et plantaris. 

(d) The moist or humid papules. 

(3) The pustular form : 

(a) Acne pustular syphilide. 

(b) Impetigo pustular syphilide. 

(c) Varicella pustular syphilide. 

(d) Ecthyma pustular syphilide. 

(e) Rupia. 

(4) The tubercular form : 

(a) Superficial syphilitic cutaneous nodes. 

(b) Deep syphilitic cutaneous nodes. 

1. The Erythema Syphilide, Erythema Syphiliticum Mac- 
ulosum et Papulatum, Roseola Syphilitica, Syphi- 
litic Spots. 

By erythema syphiliticum is understood that affection of 
the skin originating from syphilis which manifests itself by 
the formation of roundish, sharply defined, superficial inflam- 
matory foci or spots, of the size of a lentil, pea, or even larger. 
If acute, the eruption is of a bright-red color, and then lasts 
only from eighteen to twenty-four hours ; but the longer it 
lasts, the duller or more brownish-red it becomes, changing 
finally to lead or graphite gray. On pressure, the color does 
not disappear entirely. 

Syphilitic erythematous eruptions consist either of smooth 
spots which are not raised above the level of the skin (erythe- 
ma syphiliticum maculosum or roseola syphilitica), or of those 
which are provided with small papular swellings, or dots 



SYPHILIS. 181 

(erythema syphiliticum papulation). The last form is only a 
grade higher than the former ; for in acute cases it appears 
simultaneously with the first (erythema syphiliticum maculo- 
papulatum). Both eruptions are based upon a circumscribed 
inflammatory process in the papillge of the cutis ; still, the se- 
baceous and hair follicles also undergo marked pathological 
alterations. Biesiadecki regards macula syphilitica as a cir- 
cumscribed hyperemia of the blood-capillaries, resulting either 
in hemorrhage or transudation of the blood, with consequent 
discoloration. The walls of the blood-vessels of the papillae 
and of the corium are permeated and surrounded by newly 
formed cells and granules. 

Erythematous syphilitic eruptions are found in greatest 
numbers on the trunk, especially on the sides of the chest, 
groins, and abdomen. The neck, the sternal region, and the 
face generally, are free from spots ; but on the forehead, where 
the hairs cease to grow, numerous eruptions originate. On 
the extremities they are usually only found at the bends of the 
elbow and inner surface of the thigh. They very seldom ex- 
tend upon the forearm and leg down to the wrist and ankle ; 
but when this happens to be the case a few erythematous 
patches of the size of a lentil or millet-seed are found scat- 
tered upon the palm of the hand and sole of the foot (psoriasis 
palmaris and plantaris). No macular eruptions are found on 
the skin of the genital organs, except the penis. If a balano- 
blennorrhoea be present at the same time, the spots or papules 
will be transformed into elevated, sharply defined, bright-red, 
moist or easily bleeding erosions, and they may be mistaken 
for superficial chancrous ulcers. 

The development of erythema syphiliticum is generally 
preceded by the previously mentioned specific eruptive fever. 
The more intense the latter, the more numerous and pro- 
nounced will be the efflorescences. If no eruptive fever oc- 
curred, or if the patient was treated with mercurial or drastic 
purgative remedies, soon after the appearance of the Hunterian 
chancre, the spots of eruption will be few in number and 
appear slowly. After indulgence in excesses, exhausting 
marches, or in consequence of violent depressing mental dis- 
turbances, the erythema attacks the entire skin within twenty- 



182 PATHOLOGY AND TREATMENT OF SYPHILIS. 

four hours. Its slow development is the rule ; but, compared 
to the other syphilides, it develops more quickly and comes on 
earlier after the infection. Neither the season of the year, nor 
age, nor sex exercises any influence upon its development ; the 
temperature affects it to a certain extent, inasmuch as high 
temperature renders the spots less distinct, and low tempera- 
ture brings them out brighter against the pale surrounding 
skin. 

In exceedingly rare cases, the erythematous syphilide is of 
very short duration (roseola syphilitica evanida of the old writ- 
ers). As a rule, it will remain unchanged for many weeks, 
even years, if not interfered with by treatment. Although a 
mercurial treatment may dissipate the eruption in about four- 
teen days, still it often happens that, during and notwithstand- 
ing the treatment, the elementary form of the syphilitic erup- 
tion develops markedly, and desquamating papules and pustules 
result from it. The reason why erythematous efflorescences 
in some persons occasionally merge so quickly into other erup- 
tions that it is entirely overlooked, while in others syphilis 
persists in the form of an erythematous syphilide, is due neither 
to the concentration of the absorbed virus, nor to the character 
of the infecting foci, nor age, nor season of the year, but to 
the constitutional condition of the infected individual. The 
syphilitic erythema always disappears by resolution, leaving 
behind a brownish-gray mark (lentigines or ephelides syphi- 
litica of the old writers). It occurs as often in congenital syph- 
ilis as in the acquired form. The erythematous spots, when 
the eruption relapses, are larger (three to four millimetres) than 
the primary ones, and are sometimes aggregated in circles. 
They occur mostly on the abdomen and the lower part of the 
chest — less on the back. The relapses which manifest them- 
selves as erythema syphilitica generally come on a little while 
after the first eruption disappears. Still, we had one opportu- 
nity of seeing a relapse of this kind occur one year after the 
first erythema vanished. A relapse may take place so long as 
the Hunterian primary lesion or the discolored spots of the first 
eruption are not entirely gone. Febrile phenomena generally 
do not precede a relapse of an erythematous outbreak, and the 
spots usually then run a very slow course. An erythema that 



SYPHILIS. 183 

relapses is oftener accompanied by psoriasis palmaris et plan- 
taris than a primary eruption. 

It seldom happens that a person affected with erythema 
syphiliticum has not at the same time other forms of efflores- 
cence on some part of his body. Especially is this the case on 
those parts of the body where no erythematous eruptions ever 
occur ; for instance, on the scalp, in the face, and around the 
large orifices. Thus, in patients who have not been subjected 
to mercurial treatment, there are often found on the scalp in 
the third or fourth week of an existing syphilitic erythema, 
numerous, irregularly scattered, small, black, firmly adhering, 
or brittle crusts, as big as a millet-seed or larger, of a brownish 
color, or numerous yellowish or whitish small bran-like scaly 
scabs form there which are easily detached, and which are the 
result of augmented secretion of the sebaceous follicles of the 
scalp (seborrhcea sicca congestiva). Similar small crusts of the 
sebaceous glands, situated upon a reddened base, are found in 
the crevices of both alse nasi. In addition, similar impetigi- 
nous crusts, situated upon papular elevations, occur with equal 
frequency in the beard and mustache. 

On the nape of the neck, close to the scalp, also here and 
there on the trunk, there are found, after the syphilitic ery- 
thema has lasted several weeks, a number of lenticular papules 
in various stages of development. Beginning psoriasis pal- 
maris et plantaris is not so frequently observed in connection 
with syphilitic erythema. 

On obese persons, an intertrigo-like affection develops on 
the external genital organs, especially in the genito-crural fold 
and anal fissure. This condition generally encourages the for- 
mation of confluent, moist papules. According to our expe- 
rience, half of the patients who are affected with erythema- 
tous syphilides suffer also from moist papules on the genital 
organs. 

At the angles of the mouth diphtheritic exudations are often 
found, which merge into the mucous membrane of the mouth, 
and here present only an opacity of the epithelial cells {jplaques 
muqueuses of the French writers). Likewise, the mucous 
membrane of the tonsils, soft palate, and uvula, has a bluish- 
red color ; here and there it is milky, opaque. The hairs also 



184 PATHOLOGY AND TREATMENT OF SYPHILIS. 

suffer a lesion of nutrition ; they lose their gloss, and fall out 
at various places. 

Now and then some feebly marked periostoses, on the an- 
terior surface of the tibia, cranium, etc., are met with in con- 
nection with syphilitic erythema. In some cases, varicella-like 
vesicles occasionally form on the trunk, while the presence of 
acne-like or ecthyma-like pustules on the legs is not infrequent. 

Finally, it is evident that, in patients suffering from roseola 
syphilitica, the lymphatic glands accessible to the sense of 
touch must be more or less enlarged. 

Of all the diseases of the skin, erythema syphiliticum may 
be regarded as the most favorable form, inasmuch as it may 
disappear in a short time without leaving any pathological al- 
terations of the skin behind. The morbid lesions in other 
tissues occurring in connection with it are also less obstinate 
to treatment, and assume a more favorable course. When the 
syphilis, after a long interval of apparent recovery, recurs again 
in the form of an erythema, the latter is to be regarded as a fa- 
vorable prognostic sign, in so far as it indicates that the graver 
specific forms of the disease are incapable of affecting the 
system. 

In regard to the differential diagnosis, syphilitic erythema 
presents many similarities to some of the non-syphilitic erup- 
tions of the skin, such as morbilli, rubeola, scarlatina, and 
roseola typlwsa. These typical exanthemata differ from syphi- 
litic erythema by the severe febrile phenomena, which con- 
tinue even after the above-named eruptions have appeared, by 
the higher temperature and uniform hypersemia of the skin, 
by the location of the efflorescences, by the accompanying ca- 
tarrhal symptoms (in morbilli and roseolse), by the intense 
angina (in scarlatina), by the splenic tumor (in typhoid fever), 
and, finally, by the duration and the whole course of the affec- 
tions. 

The resemblance of specific erythema to urticaria and rose- 
ola balsamica was the cause that misled physicians, Cazenave 
among others, to regard the virus of gonorrhoea as identical 
with that of syphilis. Now, roseola balsamica occurs only in 
some of the patients suffering from gonorrhoea who are treated 
by the internal administration of balsam of copaiba, cubebs, 



SYPHILIS. 185 

turpentine, etc., and disappears eight or ten days after the use 
of these remedies is discontinued, without leaving any dis- 
colored spots. It is attended by intolerable itching and burn- 
ing. The violet-red efflorescences are of the size of a pea, 
have a tendency to aggregate in groups, especially in places 
where pressure is constantly kept up, generally coalesce, and 
then the skin, swollen and of a violet-red color, is seen cov- 
ered with brownish-red wheals. The temperature of the skin 
is considerably increased. Lastly, roseola balsamica is always 
attended by gastric disturbances. In addition, the chemical 
reaction of the urine, upon the addition of a strong mineral 
acid, which has already been mentioned in a former section, 
affords us sufficiently reliable evidence in differentiating the 
two exanthemata. 

In some very rare cases the internal use of mercury pro- 
duces an erythematous affection of the skin, which may be 
mistaken for the syphilitic form. Erythema mer curtate pro- 
duces not scattered, but confluent efflorescences, and large parts 
of the skin assume a bright-red color. It is localized, as in a 
case we had an opportunity of seeing, on the flexor surface of 
the forearm, and on the leg and trunk. It likewise causes a 
prickling sensation, and disappears quite quickly when the use 
of the mercurials is discontinued. 

Relapsing erythematous syphilides that appear in circular 
groups resemble very much erythema circinatum, or annularis. 
The acute course of the non-syphilitic erythemata, the almost 
exclusive appearance of the eruption on the back of the hand 
and foot, and its rapid resolution, afford sufficient guide for a 
diagnosis. 

The discolored remnants of extinct erythematous and papu- 
lar syphilides — in fact, all discolored spots produced by specific 
inflammatory processes — may be mistaken for pityriasis versi- 
color. This affection of the skin, however, is distinguished by 
the following features : The brownish spots of pityriasis are 
caused by the accumulation at certain places of discolored epi- 
dermal cells, the dark color of the syphilide is due to collec- 
tions of coloring-matter in the rete Malpighii ; the former may, 
therefore, be scraped off with the nail, or removed by baths 
and lathering ; the latter can not be so removed. The solitary 



186 PATHOLOGY AND TREATMENT OF SYPHILIS. 

spots of pityriasis versicolor coalesce after a while, and form 
irregular stains as large as the palm of the hand. This never 
occurs in syphilides. If, in addition, the fungi-spores, mi- 
crosporon furfur, and thallus fibers of pityriasis versicolor are 
seen with the microscope, in the scraped-off scales, all sources 
of diagnostic error will be avoided. 

2. Papular Syphilides. 

The papular syphilide is characterized by plano-convex, 
sometimes acuminate, painless nodular elevations, of the size 
of a poppy-seed, or even of a lentil, which, according to their 
location, will be more or less advanced in the process of evolu- 
tion or involution. These elevations constitute minute gran- 
ules or kernels, covered with a markedly dry, glossy skin, with 
or without a crust. Sometimes small granules with broad bases 
are seen, and, from their upper surface, in consequence of the 
softened condition of their epidermal covering, exudes a mi- 
nute quantity of moisture. The color of the syphilitic papule 
at first is bright red, but subsequently becomes brownish- 
red. After desquamation has taken place, the papule ac- 
quires a glossy, livid color, and, the more the resolution 
goes on, the more it grows dirty-yellowish or bluish -gray. 
Under the pressure of the finger, the developed papule turns 
yellowish. 

The specific papule develops from small or large brownish- 
red spots which gradually rise above the level of the skin. 
According to the size, we distinguish a miliary and lenticular 
papule. The syphilitic papule never attains a large size on 
the palm of the hand or sole of the foot (psoriasis palmaris and 
plantaris), while in the vicinity of the genital organs it some- 
times attains enormous dimensions (moist papule). 

This pathological process is caused by perifollicular and 
papillary cell-infiltration. The former occurs especially on 
those places where the sebaceous and hair follicles are best de- 
veloped : for instance, around the anus and the genital organs, 
in the axillary region, and, where the scalp merges into the 
hairless skin, on the forehead and nape of the neck. 

The papular syphilide originates most frequently from ac- 
quired syphilis ; congenital syphilis very seldom produces it. 



SYPHILIS. 187 

If the infected person was not treated with mercury or 
drastic purgatives, it develops soon after the appearance of 
the Hunterian primary lesion, a few days later than the ery- 
thematous syphilide, from which, in fact, it is apt to origi- 
nate. It appears, therefore, at about the eleventh or twelfth 
week after infection. But if the patient was put upon an 
antisyphilitic treatment soon after he became infected, this 
manifestation of syphilis may be postponed for an indefinite 
time, as we have stated before. Only a few papules will then 
develop, and these are arranged in circles, segments of circles, 
or ellipsoids. 

Large as well as small papules may be absorbed before they 
undergo any pathological transformation, especially with the 
aid of medicine. They leave behind almost black or bluish- 
red discolored depressions, which gradually become smooth and 
disappear. 

But if no treatment is instituted — sometimes, indeed, in 
spite of it — the papules undergo absorption, by passing through 
the most remarkable morbid changes. The epidermal cover- 
ing of the papule is raised and forms a dry, grayish scale. The 
latter falls off and is renewed again and again till the des- 
quamating place has become level with the skin. The papules 
that have already cast off their scales present, on their flat- 
tened surface, a bluish tint and a gummy gloss, and are sur- 
rounded by a whitish, undermined epidermal border. The re- 
moval of the epidermal covering of the papule, however, does 
not always take place by the dry process ; often it is the moist 
process which brings about that condition. Twelve or fourteen 
days after the papule appears, a serous effusion forms under 
the epidermal cover, thus causing, according to the size of the 
papule, the formation of a large or small vesicle. The con- 
tents of this vesicle, however, are soon absorbed or inspissated 
by evaporation, and conjointly with the elevated epidermal 
cover form a thin crust, which again undergoes desquamation. 
This process rarely happens in the lenticular papule, and in 
the moist papule it escapes observation so easily, that but few 
writers mention it. Miliary papules, especially when they 
appear under an acute form, are generally transformed into 
small pustules. 



188 PATHOLOGY AND TREATMENT OF SYPHILIS. 

(a) Lenticular, Papular Syphilide. 

The lenticular, papular syphilide is generally preceded by 
a more or less severe eruptive fever. Nevertheless, the ef- 
florescences are not very numerous, but appear in a certain de- 
gree of pathological order, so that at least eight or ten days 
elapse before the eruption has attacked the whole trunk. The 
first indications of the eruption are slightly elevated dark-red 
spots, of the size of a lentil, generally originating on the nape 
of the neck and on the forehead along the line where the 
hairs cease to grow (corona venerea). While the papules at 
these places advance in their development and metamorphosis, 
or have already undergone some retrogressive changes, new 
papular efflorescences appear all over the trunk, especially on the 
back, sides of the chest, and sometimes on the abdomen. Gener- 
ally they are pretty evenly scattered ; still, over the scapular 
and sacral region, and in the genito-crural fold, they are more 
aggregated. On the anterior surface of the upper extremity, 
the lenticular papules are less numerous and not so well de- 
veloped. They are more numerous, and tend to coalesce at 
the bend of the elbow and wrist. On the lower extremities 
they are located in the greatest numbers on the internal, in 
less numbers on the external and posterior surface of the thigh ; 
on the leg they occur almost exclusively in the bend of the 
knee, where two or three of them are usually found grouped 
together. On the dorsum of the hand and foot syphilitic 
papules are very rarely found. In the face the lenticular pap- 
ule is equally rare ; and when seen here it is not as papula 
disseminata, but arranged in circles, especially when it occurs 
in the dimple of the chin. 

Notwithstanding its acute commencement, the course of 
a lenticular papular syphilide is always protracted. If not 
modified by treatment, the papules remain stationary for a 
long while, or they desquamate several times in succession. 
After desquamating, frequently or rarely, the papules con- 
stantly grow more brownish-yellow, flat, and finally disappear 
by resolution. The places where they were situated are marked 
for months by coppery-brown or bluish-gray spots of the size 
of a lentil. 

The duration of a lenticular papular syphilide naturally de- 



SYPHILIS. 189 

pends, like that of any other syphilide, upon the life the patient 
leads and the treatment he gets. If he is not treated at all, 
the above-described desquamation will ensue in about fourteen 
days on some places, while new papules will appear on others. 
This disappearance and reappearance of new papules may go 
on for a long while ; however, later they are not so numerous, 
and are located in some places in circles, segments of circles, 
and ellipsoids. Under an appropriate treatment a papular 
syphilide usually disappears in from two to three months. 
The treatment with iodine, as a rule, requires a slightly longer 
time to effect a cure. 

Mixed in between the lenticular papules of various phases, 
there occur developed or retrograding miliary papules and 
erythematous efflorescences. Acne and ecthyma pustules are 
also met with here and there, especially on the legs. On the 
palms of the hands and soles of the feet there are found the 
traces of psoriasis palmaris and plantaris, and moist papules on 
their favorite places. The falling out of the hair and the dis- 
ease of the nails are of more frequent occurrence, and last 
longer in papular than in erythematous syphilide, and crusts 
are found correspondingly oftener in the beard and scalp. 

In regard to the lesions in other tissues, the swellings of 
the glands have, by this time, become more marked, and affec- 
tions of the mucous membrane and enlargement of the ton- 
sils, especially in relapsing papular syphilide, are more often 
observed. Iritis syphilitica is usually found accompanied by 
papular syphilis. The morbid alterations of the bones are 
similar to those occurring in erythematous syphilide. 

An apparently cured syphilis may relapse and manifest it- 
self, even after many years, by a papular syphilide. The re- 
lapsing papular syphilide is distinguished from the primary 
eruption by the fact that the efflorescences form on a few 
(one or two) places only large or small circular, ellipsoid, or 
curved lines or groups ; and, further, that no other forms of 
eruption occur between the relapsing papules. 



(b) Small Papular Syphilide (Syjihilis Papulosa Mil 

The small papular or miliary papular syphilide is so called 
on account of its minute size, being hardly larger than a millet- 



190 PATHOLOGY AND TREATMENT OF SYPHILIS. 

seed. It appears, as a rule, in a very acute form, so that in 
twenty-four or forty-eight hours large tracts of skin are covered 
with numerous groups of efflorescences. Another effect of the 
acute appearance of the granules is, that they have hardly de- 
veloped when they become acuminated, and the apices are con- 
verted into minute vesicles or pustules. Miliary papules are 
mainly located in the face, on the back, and, like lenticular 
papules, in the palm of the hand and sole of the foot, in the 
genito-crural fold, in the anal crevice, and about the genital 
organs (modifications of psoriasis syphilitica palmaris et plan- 
taris and moist papules already mentioned). 

However acutely a miliary papular syphilide may be 
ushered in, it assumes the protracted character in a few days, 
especially after the vesicular metamorphosis has ensued. The 
scales that form after the contents of the vesicles have become 
inspissated, gradually fall oif and leave bluish-red cicatricial 
depressions about the size of a pin's head. These depressions 
correspond to the excretory ducts of the diseased sebaceous 
and hair follicles, and disappear in a few weeks without leav- 
ing any traces. Sometimes a lenticular papule develops upon 
the discolored spot remaining after the miliary efflorescence 
has disappeared. 

The vesicular stage of a miliary papular syphilide lasts 
only a few days. The conical papule upon which the vesicle 
is situated persists for several weeks and months, according to 
the condition of the patient and his mode of living. 

Miliary papular syphilide, like the lenticular variety, ter- 
minates in resolution, with or without desquamation, and leaves 
no cicatrices. 

This eruption is associated with erythematous spots and 
moist lenticular papules. The phenomena that occur in other 
tissues are analogous to those which accompany the lenticular 
papular syphilide ; but in the miliary form the falling out of 
the hair is more marked. 

This eruption is less frequent than the lenticular variety ; 
in the female it occurs somewhat more often than in the male. 

Kelapses of syphilis under the form of miliary papular 
syphilide are rare ; as a rule, the recurring syphilitic eruption, 
following a miliary papular one, will be of the pustular variety. 



SYPHILIS. 191 

Kelapses of miliary papules occur either in groups, or they con- 
stitute lines arranged in circles or half-circles of desquamating 
granules. They are especially located on the forehead, on the 
nape of the neck, on the scapular region, or the internal sur- 
faces of the upper and lower extremities. 

The prognosis with regard to the blood-poisoning at the 
bottom of the disease is less favorable than that of the ery- 
thematous form, because the morbid alterations in the various 
organs and tissues, which coexist with the eruption under 
consideration, are more pronounced and more obstinate. Re- 
garded locally, the prognosis is favorable in so far as the erup- 
tion leaves no discoloration of the skin. 

The desquamating papular syphilide which many authors 
consider as a genuine syphilitic disease of the skin under the 
name of " psoriasis syphilitica," may easily be mistaken for 
psoriasis vulgaris guttata or punctata. The following are the 
differential features of the two forms of the disease : In pso- 
riasis syphilitica, the scale, as a rule, consists of a thin, yellow- 
ish, cast-off epidermal lamella ; while in psoriasis vulgaris the 
scales may be scraped off in branny flakes. In psoriasis vul- 
garis the brilliant white flake penetrates deeply into the rete 
mucosum ; in papular syphilide the scale is formed from the 
epidermis raised up by the papule. The base of the syphilitic 
papule is light brown ; in psoriasis vulgaris there is no discolor- 
ation at all, or it is bluish-red, especially on the legs. Syphilitic 
papules that are covered with scales never become confluent 
like the flakes in psoriasis vulgaris (psoriasis vulgaris diffusa). 
At the most they form, when a relapse ensues, a few circles or 
segments of circles, in which the contours of each papule re- 
main distinct. Psoriasis vulgaris occurs on the scalp and ears, 
where desquamating papular syphilide never occurs. Fur- 
ther, it appears more on the extensor than on the flexor sur- 
faces of the extremities, and especially on the tip of the elbow 
and over the patella ; while the so-called squamous syphilide is 
found more on the inner surfaces of the extremities, and very 
seldom on the elbow and knee, or the dorsum of the hands and 
feet. Psoriasis vulgaris inveterata produces a circumscribed 
thickening of the skin that is covered with scales ; desquamat- 
ing papular syphilide scarcely ever causes any thickening of 



192 PATHOLOGY AND TREATMENT OF SYPHILIS. 

the corium. "While papular syphilide is almost always accom- 
panied by marked falling out of the hair, this is not noticeable 
in psoriasis vulgaris, even when it attacks the scalp. 

The efflorescences of miliary papular syphilides resemble 
somewhat scabies, on account of which Plenk described them 
as scabies venerea. The violent itching produced by scabies, 
and the excoriations caused by the violent scratching, and, 
above all, the finding of the acarus scabiei, will decide all 
doubts concerning the nature of the malady. 

The resemblance of lichen scrophulosorum to the small 
papular syphilide formerly caused the latter to be called lichen 
syphilitica, and, according to the arrangement of the groups of 
the eruption, disseminatus or corymbosus. The granules of 
lichen scrophulosorum, being no bigger than hempseed, pre- 
sent no striking contrast by their color to the surrounding 
skin, and under anti-scrofulous treatment disappear in a short 
time, leaving neither discolored marks nor scars, while the 
small papular syphilides leave behind for a long time livid col- 
ored depressions as big as a pin's head. 

A relapsing small papular syphilide may be mistaken for 
herpes circinatus, and, owing to the resemblance between these 
two eruptions, Bicord called it herpes syphilitica circinatus. 
The very acute course of the herpes vesicles, which barely last 
more than a day, and quickly dry up into small scabs, and 
thus form a large or small circlet or wreath of scales situated 
upon a slightly inflamed base, the microscopical demonstration 
of fungi-spores and thallus fibers, the favorable local effect of 
preparations of potash are sufficient differential data to prevent 
an error in diagnosis. 

(c) The Papular Syphilide, or Squamous Syphilide of the 
Palms of the Hands and of the Soles of the Feet {Psoriasis 
Palmaris et Plantaris), and Syphilitic Diffused Affec- 
tion of the Epidermal Strata of the Hands and Feet 
{Syphilis Cornea). 

The squamous syphilide of the palms of the hands and of 
the soles of the feet in reality is a papular syphilide, whose 
solitary efflorescences are but poorly developed, while the epi- 
dermal affection becomes markedly noticeable,, owing to the 



SYPHILIS. 193 

thickening and continuous exfoliation of the skin. On the 
other hand, there is also an affection of the epidermal stratum 
of the palm of the hands occasioned by syphilis, which is due 
to morbid corneous degeneration of the epidermis, without the 
formation of papular efflorescences. 

There originate on the palms of the hands and soles of the 
feet circular, dull red spots, varying in size from that of a len- 
til to that of a pea, which gradually rise slightly above the 
level of the skin. After a while the eruption changes its color, 
and becomes reddish-brown. "When involution of the element- 
ary efflorescences begins, the epidermal covering either be- 
comes thickened in the center of the papule only or through- 
out, resulting sometimes in acuminated, then again in lamel- 
lated swellings or callosities. These hypertrophies are, how- 
ever, gradually cast off spontaneously, the exfoliation begin- 
ning at the center and progressing to the periphery, or they 
are detached by the patient. They are nothing more than 
lamellae of dead epidermis. The diseased place, after the re- 
moval of the callosity, forms a bright-red, brilliant, attenuated 
circular spot covered by a delicate epidermal disk, correspond- 
ing in size to the efflorescence, and is surrounded by a border 
of undermined skin. In some cases the corneous transforma- 
tion takes place only in the center of the papules to the extent 
of a poppy-seed, and after the corneous portion has dropped 
out they form disks, in the center of which the epidermis has 
disappeared over a surface as large as a pin's head. 

The eruption that has just been described, however, is not 
always circular in form. On the palms of the hands and soles 
of the feet there are no sebaceous or hair follicles, upon whose 
shape the round form of the syphilitic papule depends. The 
aggregation of the inflammatory cells within it, and likewise 
between the rete Malpighii and the epidermal stratum, may 
go on unhindered and irregularly. On the other hand, the 
firmness with which the cutis adheres to the subjacent fascia, 
and the thickness and diminished distensibility of the epider- 
mis, may be the cause of the flatness of the efflorescences on 
the places under consideration. 

In most cases a few (four or five) spots form at first ; these 
are gradually followed by more, all being scattered and at a con- 
13 



194 PATHOLOGY AND TREATMENT OF SYPHILIS. 

siderable distance from each other. When a papular sjphilide 
appears in a subacute form, the soles of the feet and palms of 
the hands, along with the volar surfaces of the fingers, are cov- 
ered with numerous erythematous spots or papules. When the 
disease has existed for a time, the scattered efflorescences coa- 
lesce and then form, especially in the fissures of the palms of 
the hands and on the volar surfaces of the fingers, longitudinal 
epidermal hypertrophies or exfoliations. 

In most cases the vola manus and planta pedis are simul- 
taneously attacked. There are, however, many cases in which 
the disease occurs only in the palm of the hand, and rare cases 
in which only one palm and one sole are diseased. 

In some cases psoriasis palmaris or plantaris may get well 
without medical aid. In most cases, however, new eruptions 
originate near those already desquamating, recurring even on 
the places that have exfoliated. The efflorescences thereby 
become confluent and lose their circular form. On the other 
hand, the diseased epidermal cells accumulate in large quanti- 
ties, thick patches of skin exfoliate, resulting, especially in 
the grooves of the palms of the hands and soles of the feet, in 
cracks or fissures — " rhagades syphilitica " — which cause severe 
pain at every movement, and sometimes slight bleeding. So 
long as there are only lenticular spots, resolution may be ef- 
fected in about fourteen days by treatment with mercury ; but, 
if callous thickening of the epidermal covering of the efflo- 
rescences and desquamation have already taken place, the dis- 
ease will last for months, even years — papular syphilide of the 
palms of the hands and soles of the feet being now regarded as 
one of the most obstinate diseases. Psoriasis palmaris and 
plantaris syphilitica very frequently relapses, and sometimes 
returns after many years. Indeed, save the falling out of the 
hair and the swelling of the glands, it is usually the only symp- 
tom of relapsing syphilis. 

Still another syphilitic affection occurs in rare cases on the 
palms of the hands and soles of the feet. In contradistinction 
to the maculo-papular form of psoriasis palmaris and plantaris, 
it is known as psoriasis syphilitica palmaris, or plantaris 
diffusa, or cornea. It consists of a uniform diffused, rapid 
corneous degeneration of the most superficial layers of the 



SYPHILIS. 195 

skin, whereby the affected places look as if the epidermis were 
transformed into a tine, whitish silver-brocade. 

In the vast majority of cases psoriasis palmaris and plan- 
taris syphilitica occurs in connection with erythema syphiliti- 
cum maculo-papulosum and papular syphilides, especially the 
relapsing form. In rare cases syphilitic acne and varicella ef- 
florescences are found along with it ; usually, however, marked 
falling out of the hair and onychia syphilitica occur at the same 
time. In very marked psoriasis palmaris we have seen not in- 
frequently a lymphangioitis, commencing at the wrist-joint and 
extending toward the internal surface of the forearm. 

Although psoriasis palmaris and plantaris often obstinately 
resists all kinds of treatment, nevertheless it is a good omen for 
the patient, and we are relieved of the apprehension that dan- 
gerous purulent infiltration of some delicate organs, or that ex- 
udation under the periosteum, etc., was impending. 

It is most frequently mistaken for psoriasis vulgaris pal- 
maris and plantaris ; likewise for ordinary eczema of these 
regions. 

Psoriasis vulgaris palmaris and plantaris differs from psori- 
asis syphilitica in producing much larger and more scattered 
plaques than the latter. The attacked places, being deprived 
of scales, display in vulgar psoriasis a more livid color, while 
in the syphilitic form the well-known coppery color is quite 
distinct. The epidermal scales of psoriasis vulgaris are much 
larger and more difficult to remove than the scales of psoriasis 
syphilitica ; the scales of the latter represent the hypertrophied 
epidermal lamellae, while the scales of the former are an ag- 
glomeration of diseased epidermal cells. The scales of psoriasis 
vulgaris form an elevation with a central prominence, while 
the scale of psoriasis syphilitica is defective in the center. 
Psoriasis vulgaris of the parts in question is always associated 
with general psoriasis, while psoriasis palmaris and plantaris 
caused by syphilis either occurs alone, or is attended by specific 
affections in other organs and tissues of the body. 

Eczema palmaris develops in the form of scattered or 
grouped hyaline vesicles, whose contents may be absorbed or 
evaporated, whereupon parchment-hke hypertrophied patches 
of epidermis as big as a pin's head remain. If the latter hap- 



196 PATHOLOGY AND TREATMENT OF SYPHILIS. 

pens to be arranged in groups the exudative substance may be 
pulled off in the form of yellow, thickened epidermal plates 
of the dimensions of the diseased spot. When the exudation 
recurs very often, the epidermis becomes so intensely hyper- 
trophied that, by virtue of its denseness and the xanthopro- 
tein color it acquires, it is best compared to a mummified, parch- 
ment-like hide. If a recent eczema vesicle is pricked or 
scratched open, a gummy fluid will run out. If an epidermal 
lamella is torn off", there is seen on the surface facing the cutis 
the negative impression of the former vesicle, but upon the 
cutis itself a very delicate new epidermal plate having a rosy 
or bright-red color, which after a few days becomes the site of 
a new vesicle. 

Now, if the development and course of eczema palmare are 
compared with the already delineated symptoms of psoriasis 
syphilitica palmaris, the differential signs are instantly recog- 
nized. In regard to location, psoriasis syphilitica palmaris de- 
velops more in the middle of the hand, while eczema oftener 
attacks the ulnar and radial margins. Further, in eczema pal- 
maris eczematous vesicles are usually found on the interdigital 
surfaces, or on the back of the affected fingers, which is never 
the case in psoriasis palmaris syphilitica. Finally, no form of 
eczema causes such violent itching as eczema palmare and 
plantare, while syphilitic degeneration of the epidermis of the 
palms of the hands and soles of the feet occasions no itching. 
In some cases, the occupation of the patient may also assist 
us in the formation of a differential diagnosis, as is the case 
in eczema of washer-women (psoriasis of washer- women), or in 
eczema of bakers (scabies pistorum). 

{d) The Humid or Moist Papules, or Flat Condylomata; 
Papules Humides ; Pustula Fortida Ani ; Pustules? 
Plates, etc., of various Authors. 

The moist or humid papules are dry papules metamor- 
phosed by local conditions. On examining a patient affected 
with recent papular syphilides, a few feebly developed pap- 
ules covered with dry scales are usually found on the upper 
and inner surfaces of the thighs. But the nearer the papular 
eruption approaches the genital organs,, the more developed 



SYPHILIS. 197 

will the efflorescences be ; and the more warty they are, the 
greater the quantity of viscid, decomposed fetid matter will 
they discharge. This is especially trne of corpulent women 
who are careless of their personal cleanliness. These moist 
papules often surround the anal opening like a row of buttons. 

The moist papule begins as a dark-red spot, of the size of a 
lentil, whieh gradually rises above the level of the skin, and is 
exactly like the dry papule. But, while a dry scale originates 
upon a dry papule, the epidermal cover of the humid pap- 
ule is similarly transformed by moisture into a moist, gray- 
ish-white, macerated, easily detached membrane, after whose 
removal the surface of the papule is seen like a flesh- colored 
plaque. Now, if these papules, bereft of epidermis, continue 
to be exposed to friction and maceration by the physiological 
secretions and pathological excretions from the adjacent skin 
and mucous membrane, a diphtheritic membrane (molecular 
detritus) forms upon their surfaces, whereby they acquire an 
uneven, verrucose, and nodular appearance. If this membrane 
is forcibly rubbed off, the papule will bleed considerably. 
It gradually undergoes more and more molecular disintegra- 
tion, whereby the former papular elevation is so reduced that 
it is finally indicated only by a grayish-white pseudo-membra- 
nous layer, varying in size from a lentil to a pea. If the 
molecular destruction continues, shallow or deep ulcers, dis- 
charging a dirty-grayish matter, are formed. By the coales- 
cence of several such papules undergoing disintegration, or by 
the progress of the ulcerative process upon the adjacent in- 
tegument, the papules lose their original round shape, and 
form polygonal or longitudinal ulcers (fissures). However, all 
these ulcerative processes, as a rule, only bring about a shallow 
loss of substance. 

The moist papule may, however, undergo still another 
change under favorable conditions. The newly formed cells 
of the papular inflammatory foci may develop into connective- 
tissue fibrilke, in the same manner as they undergo degenera- 
tion. In this case the papule swells up to the size of a pea or 
bean, and becomes somewhat constricted at its base, while its 
semicircular surface acquires an uneven, caruncular appear- 
ance. In the further course of the process these caruncular 



198 PATHOLOGY AND TREATMENT OF SYPHILIS. 

prominences, by luxuriant growth, develop into conical con- 
nective-tissue fibrillae, which branch off dichotomously, as in 
ordinary condylomata. 

Sometimes the molecular degeneration on the ulcerating 
papules remains quiescent, the diphtheritic membrane par- 
tially disappears, and in its place conical cicatrizing connective- 
tissue bands — i. e., condylomata acuminata — originate from the 
inflammatory foci. 

According to this description, we distinguish the following 
phases in the development of a moist papule : 

(1.) The intact papule. 

(2.) The phase of elevation and casting off of the epider- 
mal cover of the papule (pustule crust). 

(3.) The diphtheritic phase. 

(4.) The phase of the connective- tissue proliferation (syphi- 
lis vegetans, condyloma latum). 

Not every papule, however, goes through all these phases ; 
it may disappear at any phase, and a cure ensue. 

In our opinion, the dry syphilitic papule is due to cellular 
infiltration of the papilla of the skin ; the moist papules, espe- 
cially those on the edges of the labia and around the anus, to 
disease of the sebaceous glands. In some cases, moist papules 
have originated upon cicatrices of chancres, even upon the 
ulcerating surface of a soft chancre. 

In general, moist papules originate on those parts of the 
skin where large sebaceous and hair follicles are found, where 
the integument forms deep folds, where two surfaces of the 
cutis are constantly in contact with each other, causing, by the 
friction of the parts, an increase of the temperature. Such 
places are the inguinal and genito-crural folds, the folds pro- 
duced by pendulous breasts, the perinseum, the pubis, the anal 
indentation, the labia majora, the axillae, the interdigital folds, 
and between the toes and at the navel. The thicker the laj^er 
of adipose tissue upon the places mentioned, the more they are 
irritated by sebaceous, perspiratory, and other secretions, the 
more exuberantly and abundantly will papules develop. In ad- 
dition to the places mentioned, the moist papule is met with on 
the nipples of wet-nurses, the angles of the mouth and lips of 
smokers of pipes and cornet-players ; sometimes on the groove 



SYPHILIS. 199 

at the alae nasi, the meatus auditorus externus, and very rarely 
in the grooves of the nails. They are found in greatest abun- 
dance and more closely aggregated on the margins of the large 
apertures of the body, where the mucous membrane joins the 
integument. 

The moist papules situated upon the genital organs and 
around the anus usually produce severe itching, and when they 
become ulcerated occasion intense pain and functional disturb- 
ances. Ulcerating papules around the anus render the evacu- 
ation of the bowels painful ; those on the surfaces between the 
toes hinder the patient in walking ; those situated on the nip- 
ples of the mother or wet-nurse's breast, interfere greatly 
with the function of wet-nursing, while those situated on the 
lips of the nursling hinder it in sucking the breast. The de- 
composing discharge from moist papules not only produces an 
injurious effect upon other papules that come in contact with 
them, but also occasion an erythematous inflammation and ex- 
coriation of the adjacent parts. Moist papules on the labia, if 
numerous and undergoing suppuration, will cause the latter to 
swell enormously, while the absorption of the ichorous matter 
from those papules situated near the genital organs will give 
rise to acute enlargement of the indolent inguinal buboes, and 
result in softening and suppuration. 

Moist papules, if situated on parts of the skin that are in 
contact, will, if not kept asunder by the interposition of bits 
of lint, etc., and kept perfectly clean, produce similar papules 
on the opposite surface. Tins condition, however, is not to be 
regarded as an instance of spontaneous inoculation, but as an 
effect of irritation on a part that is less capable of resistance — 
a morbid lesion reproducing itself by simple impression. 

The etiological factor that is capable of generating a moist 
papule on one place acts also upon the other, and, fostered by 
the foul secretion of the morbidly changed surface, exercises 
its effects upon an apparently healthy contiguous part. 

Notwithstanding the acute and inflammatory manner in 
which moist papules are ushered in, they, like other syphilides, 
run a chronic course. The elevation and removal of the epi- 
dermal cover of the moist papule are usually completed in a 
few days. The diphtheritic stage, however, will last several 



200 PATHOLOGY AND TREATMENT OF SYPHILIS. 

weeks ; indeed, not infrequently several months, if left with- 
out treatment. Under an appropriate local and general treat- 
ment, the papules undergo resolution quite rapidly, and will 
be entirely absorbed, while the vegetations situated upon 
them, if not removed by escharotics or instruments, will shrink 
and drop off. As soon as absorption begins, the discharge 
ceases, and the papule becomes dry. If many moist papules 
are grouped together, those situated in the center of the group 
generally disappear first, and those on the periphery then 
form a circle. The non-ulcerating papule, after having been 
completely absorbed, leaves a copper-colored stain of corre- 
sponding dimensions. An ulcerating papule heals by the 
formation of a very superficial scar, which likewise remains 
brownish-red. This discolored spot disappears only after pro- 
longed treatment. Occasionally the scar is characterized by 
the absence of coloring-matter in it. 

The moist papule is one of the most frequent forms of the 
syphilides, but it occurs oftener in females than in males. It 
is usually the prodroma of commencing or recurring syphilitic 
eruptions. It is, however, not only the product of acquired, 
but also occurs as a symptom of hereditary syphilis. 

No syphilide relapses as often as the moist . papule. Re- 
lapsing moist papules may reappear upon their former site. 
They are then usually less numerous the longer the time that 
has elapsed since infection took place ; they discharge less 
matter and itch less, are less painful and develop more slowly. 

The moist papule is not infrequently the only morbid 
lesion on the skin by which syphilis manifests itself — i. e., a 
relapse of the first phases of syphilis is often noticeable by the 
sole appearance of moist papules. As a rule, however, they 
are attended by the macular and papular and also by pustular 
syphilides. The lesions which occur in the other tissues are 
identical with those of the dry papular syphilide. 

Confluent moist papules, when a contiguous part of the 
skin is rendered sore by their discharge, may be mistaken for 
an eczema rubrum. The distinctive signs are : The eczema- 
tous skin that is denuded of epidermis generally does not pre- 
sent that dirty-grayish, shaggy appearance which is peculiar to 
papules covered with molecular detritus. The secretion in 



SYPHILIS. 201 

eczema is more profuse and the itching much more severe 
than that produced by moist papules. Eczema heals from the 
periphery toward the center ; confluent moist papules from the 
center toward the periphery. In eczema there is found, on 
the extreme periphery of the affected places, new vesicles, or 
their former presence is indicated by scales of corresponding 
dimensions. At the external border of the place on which 
moist papules are situated isolated ulcerating or non-ulcerating 
papules are occasionally seen. 

Isolated moist papules may be mistaken for a diphtheritic 
chancroid. The slow result produced by inoculations with 
the secretion of a moist papule on the person bearing it, and 
still better the course it pursues, will furnish the best proof of 
the nature of the lesion in question. In conclusion, we will 
add that a granulating external orifice of a rectal fistula may 
readily be mistaken for a moist papule. 

3. Pustular Syphilide. 

By the term, pustular syphilide we understand a form of 
skin-disease produced by syphilitic poisoning of the blood, 
whose efflorescences consist of pustules (according to Willan) 
which originate from a more or less marked elementary papu- 
lar eruption. According to the variation of the purulent trans- 
formation of this papular eruption, we distinguish different 
kinds of pustular efflorescences. Thus, if the apex of the pap- 
ule alone undergoes softening, a pustular syphilide originates 
that is analogous to acne and varicella vulgaris. If the entire 
papular inflammatory focus undergoes purulent metamorpho- 
sis, without, however, affecting the corium deeply, the vesicu- 
lar or impetiginous form will ensue. But if the purulent 
softening attacks the corium very deeply, then we have ecthyma 
syphiliticum or rupia syphilitica. The most frequent form is 
ecthyma syphiliticum ; less frequent is impetigo syphiliticum ; 
still more rare is acne syphilitica ; and the rarest of all forms 
are varicella and rupia syphilitica. 

The pustular syphilid es, compared with the dry, occur in 
the proportions of seventy to one hundred, and generally come 
on at a later period after infection. The pustular form of 
syphilis always casts a mournful shadow upon the condition of 



202 PATHOLOGY AND TREATMENT OF SYPHILIS. 

the patient, and justifies the fear that the inflammatory foci 
coexisting in other tissues, as a result of syphilis, are also un- 
dergoing purulent metamorphosis. 

The accompanying phenomena of pustular syphilides are 
about the same as those of other syphilides, the only difference 
being that here we have to deal with a still greater variety of 
efflorescences. For, in addition to the pustules in various 
stages of development, there are also present maculae, papu- 
lae, squamae — indeed, even ulcers. Induration of the testicle 
and suppurative paronychia occur oftener in pustular syphi- 
lides than in other forms. Enlargement of the glands in gen- 
eral is usually more pronounced than in dry syphilides. 

(a) The Acne-like Syphilid e. 

By the term acne syphilitica is meant a small, generally 
acuminated, more rarely spherical pustule, upon which a papu- 
lar inflammatory focus is located. In its further course it 
dries up, and forms a brownish or yellowish crust. The ana- 
tomical site of acne syphilitica, as in acne vulgaris, is the seba- 
ceous and hair follicles. The aeneous syphilitic efflorescences 
are met with simultaneously on the hairy part of the head and 
face, sometimes on the scapular, the lumbar, and sacral regions, 
while on the breast and abdomen very few, and on the extremi- 
ties the least, are seen. 

Acne syphilitica is apt to be the earliest of all pustular 
eruptions following an infection, and of all of them runs the 
most rapid course. 

It may appear in a subacute or chronic form. In the 
former, the eruption is preceded for three or four days by feb- 
rile movement which increases toward evening. On the places 
that have been mentioned small granules, varying from the 
size of a millet-seed to that of a lentil, then form. They are 
all the more uniformly and extensively disseminated the more 
quietly the acne appears (acne syphilitica disseminata). In the 
chronic variety the efflorescences develop gradually in batches, 
are less numerous, and are collected into groups (acne syphi- 
litica conferta). The latter form may always be regarded as a 
relapse. The more acute the efflorescences form, the more 
distinctly and rapidly the purulent transformation at the apex 



SYPHILIS. 203 

of the granules will take place. The redness of the grannie 
thereby becomes dull, more brownish in color, and on its apex 
an acuminated little pustule of the size of a pin's head forms. 
Part of the contents of this little pustule is absorbed, another 
part dries, and results in a thin scab. After the desiccation 
and decrustation of the pustular apex the papular base acquires 
a glossy appearance, and desquamates several times in succes- 
sion. On some decrustated acne efflorescences another pustule 
forms, which, however, is natter than the preceding one, the 
entire papule becoming involved, and the pus subsequently 
dries up and forms a crust. The scales, after falling off, leave 
a minute depression, barely the size of a pin's head, which in 
time becomes imperceptible. It often requires three to four 
weeks, or even a longer period, for a pustule to become dry 
and form a crust. 

However acute the eruption of acne syphilitica may be, 
it soon assumes the protracted character of all syphilides. ISTew 
efflorescences crop out from time to time amid those already 
existing, and if the patient remains untreated the acne-pustules 
may develop into ecthyma-pustules. Acne syphilitica is likely 
to resist the most appropriate treatment for six or eight weeks. 

It is usually accompanied by erythema syphiliticum macu- 
losum and papillosum, or papular syphilide, while acne syphi- 
litica conferta s. gyrata, occurring as a manifestation of a re- 
lapse of the disease, is associated with ecthyma and nodes. 
Opacities of the mucous membranes (plaques muqueuses) in 
the mouth, on the tonsils, and on the uvula always, and perios- 
titis sometimes, coexist with acne syphilitica. 

The prognosis of syphilis in cases of acne-like syphilides is 
less favorable than in those of erythematous and papular syphi- 
lides ; its local bearing, however, is in so far still favorable, as 
no permanent cicatrices remain on the skin. Acne syphilitica 
disseminata, as a rule, disappears quicker than acne syphilitica 
conferta or gyrata. 

Acne syphilitica disseminata may readily be mistaken for 
acne vulgaris disseminata. These two cutaneous diseases differ 
from each other in the following respects : In acne syphilitica 
the pustule is situated only on the top of a papular base ; in 
acne vulgaris, on the contrary, suppuration penetrates down to 



204 PATHOLOGY AND TREATMENT OF SYPHILIS. 

the cutis. The vulgar acne efflorescence is a miniature follicu- 
lar furuncle, from which, by slight pressure, a purulent core 
may be squeezed out. This is not true of specific acne efflores- 
cences. On acne vulgaris the crusts form sooner, are larger, 
denser, seem to be wedged into the skin, and adhere firmly to 
it ; the crusts of syphilitic acne are soft and easily removed. 
The efflorescences of acne vulgaris are surrounded by an in- 
tensely red areola, while the papular base of acne syphilitica is 
sharply outlined, and has a coppery color. Acne vulgaris leaves 
permanent, oval scars — acne syphilitica small funnel-like de- 
pressions, which disappear without leaving any traces. A 
syphilitic acne efflorescence may become transformed into a 
desquamating papule — in the vulgar acne eruption this does not 
occur. Acne vulgaris, as a rule, attacks only the upper parts 
of the body ; acne syphilitica may also be met with on the 
lower extremities. 

(b) Varicella-like Syphilide or Varicella Syphilitica. 

Varicella syphilitica is characterized by a round pustule 
with a depressed apex, varying in size from that of a lentil to 
that of a pea ; it is surrounded at first by a coppery areola, 
containing thin purulent matter, which gradually becomes 
inspissated, so that the eruption resembles variola modificata. 
The majority of syphilitic varicella pustules are situated in fol- 
licles, but some of them also develop on places where no seba- 
ceous glands occur — for instance, the hands and feet. They 
occur in acquired as also in congenital syphilis. We therefore 
distinguish varicella syphilitica adultorum and neonatorum. 

Varicella syphilitica adultorum occurs under two forms — 
namely, varicella syphilitica disseminata and varicella syphi- 
litica confluens. 

Varicella syphilitica disseminata develops occasionally 
even before the Hunterian chancre has cicatrized ; often, how- 
ever, not till the induration of the chancre has entirely disap- 
peared, having been preceded or accompanied by erythema 
syphilitica. Eound dark-red spots form, and vary in size from 
that of a lentil to that of a pea. They become converted in 
twenty-four hours into spherical pustules that are surrounded 
by a red halo. In about two days the pustule loses its round 



SYPHILIS. 205 

form in consequence of the partial absorption of its purulent 
contents, and becomes flattened and umbilicated. The cover 
of the pustule sinks lower and lower, and finally is transformed 
into a thin crust, which after it falls off leaves a dark or bluish- 
red depression. After the depression on the apex has formed, 
the pustules sometimes grow larger in circumference, extend 
over the former areola, and a new one forms around it. The 
eruption generally lasts six or eight weeks, and even longer. 
As a rule, there are only a few pustules ; most of them are 
met with in the face, on the forehead, and here and there on 
the flexor surfaces of the extremities; occasionally on the 
trunk too. It takes from two to eight months to get well, 
because new crops of the eruption form from time to time. 

Varicella syphilitica conjluens adultorum, or pemphigus 
syphiliticus adultorum of the syphilidologists, is characterized 
by flat, greenish-yellow, epidermal blebs of the size of a pea, 
filled with pus, and surrounded by an areola ; the blebs gradu- 
ally coalesce and form a large vesicle. This eruption is so 
rare that H. Zeissl has seen it only once in thirty thousand 
syphilitic patients. In this case the vesicles were found on the 
volar surfaces of both hands, on the dorsal surfaces of some of 
the fingers, and on both elbows. 

Varicella syphilitica adultoriim disseminata is most fre- 
quently associated with erythema syphiliticum maculosum or 
papulosum. Impetiginous pustules are apt to occur on the 
hairy part of the face and head in connection with it. The 
prognosis of this form of varicella is as unfavorable as that of 
all the pm-ulent syphilides ; still, it is more favorable than that 
of impetigo, ecthyma, and rupia syphilitica, because it heals 
without leaving scars. ^Neither have we seen an instance in 
which this eruption relapses, which certainly can not be said 
of the confluent form of syphilitic varicella. 

A varicella-like syphilide is most likely to be mistaken for 
varicella vulgaris. The distinguishing signs are : The eruptive 
fever of varicella syphilitica never becomes as violent as in 
ordinary varicella, and subsides as soon as the eruption has ap- 
peared, while in the latter it continues. The skin in varicella 
syphilitica is not only not increased in temperature and is not 
red, but. sometimes it is even pale and chlorotic. The efflo- 



206 PATHOLOGY AND TREATMENT OF SYPHILIS. 

rescences, as a rule, are less numerous in syphilitic varicella 
than in variola modificata, and in the latter the groups of ef- 
florescences do not assume a circular form. The pustules of 
the syphilide are not as tense, nor do they dry up as quickly, 
as those of variola modificata, and still less than those of vari- 
cella vulgaris. Lastly, the eruption of syphilitic varicella lasts 
much longer than that of varicella vulgaris or of variola modi- 
ficata. The pustules of varicella syphilitica are distinguished 
from the pustules of glanders by being decidedly smaller, 
surrounded by smaller areolae, and filled with a clear liquid, 
while the latter are surrounded by larger and more inflamed 
zones, and generally filled with bloody pus. Further, the fol- 
lowing characteristic features of glanders pustules will serve as 
additional help in forming a diagnosis : The violent fever, de- 
lirium, and sopor of the patient, the bed-sores that soon form, 
the ichorous discharge from the nasal mucous membrane, and 
the speedy fatal end. 

(c) Impetigo Syphilitica. 

By the term impetigo syphilitica is meant a perifollicu- 
lar exudative process in the skin occurring as a result of syphi- 
lis, which quickly brings about a purulent condition of the 
exudation, whereby the epidermis becomes elevated, and forms 
irregular, flat, yellowish-green psydrazical pustules. 

In the development of impetigo syphilitica a papular stage, 
or stadium cruditatis, which lasts only three or four days, and 
a stadium suppurationis, may be distinguished. 

The papular stage is characterized by the formation of infil- 
trated places on the skin, varying in size from that of a lentil 
to that of a pea. The infiltrated places are irregular in shape, 
raised slightly above the level of the skin, and violet-red or 
brownish in color. The softening of the exudation raises up 
the epidermis on the affected places, and then there originate 
flat, soft, roundish pustular efflorescences which are surrounded 
by a violet-red, sharply defined areola. The epidermal cover, 
however, soon bursts, and a sticky, dirty-yellow matter escapes, 
which dries up and forms flat or stalactite-like crusts. On vio- 
lently tearing off the crust, a reddish-black, bleeding spot is laid 
bare, which soon becomes covered with a new but thinner 



SYPHILIS. 207 

scab. Beneath the latter a new epidermis generally forms, 
and after the scab has fallen off a coppery-red, slightly de- 
pressed spot remains, which gradually, though after a long 
while, becomes smooth and pale. Sometimes, however, there 
originate npon the nicer beneath the crust caruncular, wart- 
like excrescences, resembling mulberry or raspberry growths, 
which are nothing more than exuberant granulations, the new 
cells not having undergone either purulent transformation or 
disintegration, but being converted into spindle-shaped cells 
and connective-tissue fibrillge. The French physicians call 
this form impetigo d base Sieves. We, however, prefer to re- 
tain the name of "frambosia" or myrmekia syphilitica, as 
being more appropriate. The warty elevations are gradually 
absorbed, and afterward the affected places remain bluish-red 
or coppery for a long time. 

Impetigo syphilitica seems to have a predilection for the 
tender parts of the skin, such as the scalp and beard, the com- 
missures of the lips, the nasal orifices, the grooves of the alse 
nasi, the axillae, and the scrotum ; it occurs less frequently on 
the trunk and extremities. At the angles of the mouth im- 
petigo crusts merge into plaques muqueuses on the mucous 
membrane. The impetigo-spots situated in the beard and on 
the scalp generally leave behind them alopecia areata. As in all 
syphilides there are cases of impetigo which appear soon after 
infection took place in a disseminated form, while in others 
the eruption comes on long after the development of confluent 
groups on circumscribed places. In the confluent variety con- 
nected, blackish-brown, thin, and soft crusts form, which ad- 
here very loosely to the surface of the exuding and slightly 
thickened skin. Gradually, however, the purulent collection 
under the crusts dries, the latter become more solid, adhere 
more firmly, the center is depressed, while on the periphery 
new pustules and crusts form in a serpiginous manner. If 
such coherent crusts exist for a long time, the softening will 
penetrate deeper and deeper into the cutis structure, and then 
there originate in the periphery of the already formed scabs 
kidney-shaped superficial serpiginous ulcers. After cicatriza- 
tion has taken place, a bluish-red or coppery-colored superficial 
scar remains, which desquamates for a long time, and gradually 



208 PATHOLOGY AND TREATMENT OF SYPHILIS. 

becomes pale. We have seldom seen this form, and when it 
occurs it is only found in the vicinity of the genital organs, on 
the extensor surfaces of the forearm, and of the leg; some- 
times, however, on the abdomen and back. 

Impetigo syphilitica disseminata generally requires several 
months for a complete cure ; the confluent form a whole year 
and even longer. With the first form the early syphilides, 
such as erythema maculatum and papulatum, the desquamat- 
ing papular, or the varicella syphilitica ; with the latter the 
tardy syphilides, namely, ecthyma or rupia, are associated. 

Impetigo syphilitica disseminata is still a tolerably favor- 
able form of syphilide, since, with the exception of a limited 
amount of alopecia of the head and beard, it leaves no disfig- 
urement; while the confluent forms, but especially those to 
which serpiginous ulceration has become superadded, admits 
only of an extremely unfavorable prognosis, in view not only 
of the local disfiguring cicatrices, but also as an indication of 
the obstinacy of the disease and the deep inroads it has made 
into the system. This is evidenced by albuminuria and the 
cachectic appearance of the patient, and offers a very grave 
prognosis. 

Impetigo syphilitica may be mistaken for impetigo vul- 
garis. It is distinguished from the latter by the fact that the 
crusts require a longer time to form than in impetigo vulgaris ; 
the syphilitic crust remains soft for a long while, and may be 
easily raised from the still suppurating base, while the crust of 
impetigo vulgaris is denser, firmer, and more brittle, and ad- 
heres firmly to its base. In impetigo vulgaris the areolse dis- 
appear when the pustule dries, while, in syphilitic impetigo, 
the areola remains even after the crust is fully developed. 
Furthermore, the crusts in impetigo vulgaris are surrounded 
by a margin of whitish scales, which never happens in specific 
impetigo. Connective tissue, adventitious growths under the 
crusts are of the rarest occurrence in vulgar impetigo, and 
when they do occur they are rapidly absorbed, while in im- 
petigo syphilitica elevata adventitious growths are often pres- 
ent, and remain for a long time after the crusts have fallen 
off, or they may undergo molecular disintegration. 

Impetigo syphilitica may be mistaken for folliculitis har- 



SYPHILIS. 209 

bee, menti, labii superiosis, or sycosis larlce jpustulosa. Syco- 
sis, however, is a process that penetrates much deeper into the 
cutis than impetigo syphilitica. Consequently, in sycosis the 
infiltrated skin of the affected places is very thick ; this is not 
true of impetigo, the process in the latter being located more 
superficially. In impetigo syphilitica the hairs of the beard 
fall out very quickly, and none ever grow after recovery (alo- 
pecia areata). In sycosis the hairs of the beard do not fall out 
at all or very late, and if a cure has been effected early they 
will grow again. Sycosis attacks only the beard, the eye- 
lashes and eyebrows ; syphilitic impetigo usually occurs at the 
same time on the scalp too. 

The latter is apt to spread somewhat beyond the growth of 
the hairs on the forehead, on the cheeks, or on the ears, and 
there form confluent pustules, greatly resembling the morbid 
picture produced by eczema rubrwn or impetigi?iosvm. But 
impetigo syphilitica confluens is distinguished from eczema by 
the periphery of the latter being pale and indistinct, while the 
syphilitic impetiginous pustules are very sharply defined. Fur- 
thermore, the discharge in eczema is much thinner than in the 
impetiginous syphilide. Eczema forms an adherent scale, re- 
sembling flakes made of a solution of rock-candy, while specific 
impetigo produces greenish-yellow, soft scabs that may be easily 
detached from the pustules. 

(d) Ecthyma Syphiliticum, 

Ecthyma syphiliticum is characterized by pustules varying 
in size from that of a lentil to that of a bean, situated upon 
inflamed, infiltrated bases, surrounded by red zones, and gen- 
erally contain sanious or bloody pus. 

Ecthyma pustules either occur in scattered uniform efflores- 
cences or a group of smaller spots is found around a large one 
on some part. They may form on any part of the body, but 
are most frequently met with on the scalp and legs. 

The ecthyma pustule may develop in a twofold manner. 
An injected place,- of a violet color, and varying in size from 
that of a lentil to that of a bean, forms, and then upon this, in 
twenty-four to forty-eight hours, a pustule develops, at the 
periphery of which the skin soon becomes infiltrated (ecthy- 
14 



210 PATHOLOGY AND TREATMENT OF SYPHILIS. 

ma superficialis). Or the primary congestion increases, exuda- 
tion takes place, and from it a pustule results (ecthyma pro- 
fundum). 

At first the pustules contain a thin, serous fluid, which, 
however, soon becomes thicker and purulent. In most cases 
the pus is ' mixed with some blood. The longer the pustule 
grows the redder it becomes, and the more the area is infil- 
trated. The cover of the pustule is seen to be soft and flabby, 
like that of other syphilitic pustular eruptions. After a few 
days the central part of the pustule collapses, becomes dry, and 
a rusty-colored or blackish-brown crust forms, which, owing 
to the continuation of the suppuration beneath it, keeps on 
growing thicker, and, at least at first, is easily detached. Un- 
derneath the crust an ulcer is found, varying in extent accord- 
ing to the intensity of the infiltration. The ulcer is surrounded 
by a steep border, and the cavity is filled with a grayish tena- 
cious mass of molecular detritus, which erodes adjacent tissues, 
and not only fosters the deep destruction of the cutis, but also 
its peripheral disintegration. 

In ecthyma profundum the crust is always thicker, and the 
ulcer of the cutis is likewise scooped out more. Sometimes it 
extends beyond the margins of the ulcer, and then again it 
may leave the cavity partially uncovered ; and thus it seems 
to be surrounded by a soft, purulent furrow. The center of 
the crust, being the oldest point of the pustule, is depressed if 
the ulceration extends in circumference. 

As soon as the inflammatory process subsides at the pe- 
riphery of the ulcer, granulations begin to form at the bottom, 
the crust becomes denser and adheres more firmly, but sooner 
or later falls off. This leaves a depressed, dark-red scar, which 
is apt to desquamate a long time, but gradually becomes pale, 
even paler than the surrounding normal skin. In superficial 
ecthyma, after the crust has fallen off, the cutis is found in- 
filtrated in the form of a papular elevation, whose surface, how- 
ever, readily becomes eroded and ulcerated. 

The course of the eruption, notwithstanding its acute be- 
ginning, is very tardy. This is shown on the different spots 
by the fact that the red areolae surrounding them gradually 
become dark-brown or coppery. 



SYPHILIS. 211 

A period of six months or more generally elapses from the 
time the infection occurred till an eruption of ecthyma appears. 
An outbreak of this syphilide is usually ushered in with severe 
febrile movement ; and if ecthyma profundum lasts for a long 
while, remittent febrile symptoms of a hectic character super- 
vene (febris hectica syphilitica). 

Ecthyma syphiliticum occurs in connection with erythema 
maculosum and papulosum, with desquamating papules, as well 
as with other pustular syphilides, especially acne and impetigo 
syphilitica. Onychia, falling out of the hair, mucous patches, 
ulcers on the tonsils and in the fauces, and iritis, not infre- 
quently are associated with this exanthema. In men we have 
often seen syphilitic orchitis accompany specific ecthyma. 

The pustules may remain for weeks without undergoing 
desiccation. We have seen some pustules of syphilitic ecthyma 
persist for more than a year, and relapse, notwithstanding the 
most judicious treatment. 

The prognosis, both general and local, of this eruption, is 
more grave than that of any of the syphilides already de- 
scribed. Ecthyma leaves disfiguring cicatrices. Relapses oc- 
cur frequently. There is a remarkable tendency to suppura- 
tion of the complicating inflammations in all the organs and 
tissues of the body. 

This eruption is most likely to be mistaken for ecthyma 
vulgare cachecticum luridwn / but ecthyma vulgare is more 
like furunculosis, or like the boils occurring in ecthyma 
nodosum or contusiforme. It is more painful, the areolae 
surrounding the sores shade off gradually, and have more of 
a bluish than coppery color, with a greenish tint on the pe- 
riphery. Furthermore, in ecthyma vulgare there is less tend- 
ency to purulent degeneration, and the suppuration is more 
superficial. The furuncular eruptions become soft, rupture, 
and a quantity of sanious fluid escapes. Ecthyma vulgare luri- 
dum usually occurs only on the legs, especially in the most 
wretchedly intemperate or scorbutic persons. 

(e) JRupia Syphilitica. 

By the term rupia syphilitica, syphilitic filth-tetter (pviro? — 
sordes), is meant an uneven, dirty, rusty-brown-colored crust, 



212 PATHOLOGY AND TREATMENT OF SYPHILIS. 

situated upon an nicer that penetrates more or less into the 
cutis, hemmed in by a pustular wall, and surrounded by a livid, 
inflammatory zone. 

The eruption appears at about the same time as ecthyma, 
and is always attended by febrile phenomena. The elementary 
skin-disease of rupia syphilitica consists of livid papular inflam- 
matory foci, varying in size from a pea to that of a bean, which 
are transformed within twenty-four or forty-eight hours into 
flabby blebs, filled with a dirty-colored or bloody matter. The 
center of these blebs sinks in, and in two or three days they 
dry up entirely. The blebs grow in circumference by new pus- 
tules forming on their outskirts in circles, surrounded by are- 
olae, which in turn dry up. In this manner a rupia crust may 
attain a diameter of two to four centimetres. The crust is 
uneven, thickest in the center, becomes flatter at the edges, 
thereby acquiring the form of an oyster-shelL 

If the crust is forcibly pulled off, there is found under- 
neath a filthy-looking, dusky, flabby ulcer, having steep, under- 
mined, livid margins, which secrete a sanious ichor. 

A rupia ulcer heals in the same manner as an ecthyma sore. 
Not infrequently, however, it happens that only a segment of 
the rupia ulcer heals by cicatrization, while the ulceration goes 
on in the opposite direction, and a crescentric or kidney-shaped 
ulcer is the result. 

Rupia pustules occur either in large numbers of the size 
of a bean, or very sparsely, and then they are as large as a 
dollar. The smaller form may cover the trunk and extremi- 
ties in thick groups, while the larger will be represented by 
three or four crusts only, which are usually situated on the 
extensor surfaces of the limbs. 

The average duration of a rupia pustule is two to three 
months. 

The attending phenomena of specific rupia are like those 
accompanying ecthyma syphilitica ; but, in addition, we have 
in the former a more frequent occurrence of caries,, and still 
more of ulcers of the fauces. Furthermore, the terribly viti- 
ated condition of the system is always associated with albumi- 
nuria, hematuria, and scorbutic lesions. In consequence of 
these complications, the prognosis is even more unfavorable 



SYPHILIS. 213 

than in syphilitic ecthyma. Of the patients who snccnmb to 
syphilis, the great majority suffer from rnpia. 

According to our experience, specific rupia originates only 
in consequence of acquired syphilis. "We have never seen an 
instance of this eruption in children suffering from congenital 
syphilis. 

4. NODULAR SYPHILIDE OF THE SkIN J TuBERA SYPHILITICA ; 

Ttjbercula Syphilitica ; Syphilitic Nodes of the Cutis 

AND OF THE SUBCUTANEOUS CELLULAR TlSSUE (GuMMATA) ; 

Syphiloma, according to Wagner. 

Syphilitic nodes are due to a morbid proliferation in the 
cutis or subcutaneous cellular tissue, in consequence of which 
globular tumors form on the surface of the skin. Hence, we 
may distinguish deep and superficial syphilitic cutaneous 
nodes. The superficial ones are small — about as big as a pea ; 
the deep nodes are as big as beans, or even hazel-nuts ; conse- 
quently, the superficial nodular syphilid e may also be called 
the small, and the deep the large, nodular syphilide. 

Superficial syphilitic nodes originate either from a mesh of 
the corium, or from one or several adjacent cutaneous follicles, 
and develop in the same manner as a furuncle, but with less pain, 
and also much more slowly. When the inflammatory foci have 
attained the size of a lentil, the surface of the affected places 
of the skin becomes engorged, and the patients experience pain, 
which is aggravated on pressure. If the cutaneous kernel con- 
tinues to develop, a dusky-colored spot, as big as a pea, ap- 
pears, gradually grows, and forms a dark-red globular node. 

The deep syphilitic nodes start in the subcutaneous cellular 
tissue, where small movable kernels, as big as bird-shot, form. 
On external pressure they are somewhat painful. As the 
nodule continues to grow, the overlying skin acquires a red 
color and becomes adherent to it, and in connection with it 
forms a tumor. After many months or years this attains the 
size of a bean or of a hazel-nut. 

The small nodular syphilide attains its usual size in a 
short time. In some cases only small nodes — i. e., cutaneous 
nodes — originate throughout ; in others only large ones — i. e., 
subcutaneous nodes • in most cases, however, cutaneous nodes 



214 PATHOLOGY AND TREATMENT OF SYPHILIS. 

will be found on one part of the body, and subcutaneous ones 
on another part. 

The developed syphilitic node is generally globular, some- 
times conical or acuminated, not infrequently it is flattened. 
In color and consistency the node varies according to its age 
and phase of development. The recent but fully developed 
node has a brownish-red or coppery color, is flat, glossy, and 
hard. The older the nodes are, and the nearer they approach 
the regressive stage of metamorphosis, the paler they become. 
When absorption sets in they turn brown, and, after they are 
entirely absorbed, grayish discolored spots will remain for a 
while. If a node is about to undergo ulceration it turns livid, 
soft, and doughy, and sometimes fluctuation may be detected 
in it. 

In its histological development the cutaneous node resem- 
bles very much the syphilitic connective-tissue nodes or gum- 
ma. According to Wagner's researches, the syphilitic node, 
which he regards as a new growth, presents itself, when recent, 
as a grayish, soft, homogeneous, dry mass, yielding a slight 
amount of slimy, clear, or murky juice. The neoplasm forms 
either a nodular mass, varying in size, round or irregular, some- 
times sharply defined, or it is a diffused infiltration of varying 
dimensions ; or, lastly, nodular masses appear in a diffuse in- 
filtration. The most important elements of this neoplastic 
growth are cells and granules, such as we find in a Hunterian 
indurated primary lesion and in other syphilitic inflammatory 
processes. They lie, partly singly, partly in numbers, in cavi- 
ties formed by connective tissue, but which are by no means 
characteristic of this lesion. The older the node is, the less 
numerous are the cellular elements, and the more extensive is 
the connective tissue. After existing for a variable period the 
node either becomes very dry or it undergoes ulceration, or 
both morbid changes go on together. Simple and fatty atro- 
phy of the cells and granules is the most frequent meta- 
morphosis. The central and oldest part of the neoplasm un- 
dergoes metamorphosis first and thence it spreads to the 
circumference. 

According to Yirchow, a syphilitic node most closely re- 
sembles recent granulation- tissue, and the process that takes 



SYPHILIS. 215 

place in it differs from the usual ulceration and suppuration 
only in so far that no healthy or good pus forms, but only a 
tenacious (gummous), slimy, disorganized substance. Owing 
to this glutinous, synovial-like substance, the syphilitic nodules 
received the name of gummata. Wagner suggests the term 
" syphiloma." 

The external form of a specific node changes according to 
the manner in which the retrogressive metamorphosis is in- 
augurated. 

If the nodes are about to be absorbed by fatty degeneration 
they first become pale and flat, and the cutis covering them be- 
gins to shrink. After having desquamated repeatedly, they en- 
tirely disappear, leaving a slightly depressed spot — i. e., a cir- 
cumscribed atrophy of the skin. The depressed spot remains 
bluish-red for a long while; finally, the pigment disappears 
and the scar becomes peculiarly whitish. Nodes are absorbed 
only under the most favorable circumstances in robust, healthy 
persons. Under less favorable conditions, in constitutions that 
have become debilitated, central softening usually ensues. This 
will manifest itself in a different manner, according as the 
nodes are of the cutaneous or subcutaneous variety. 

If the node that undergoes disintegration is of the cutane- 
ous species, a small quantity of serous fluid will be poured out 
under the glossy epidermis covering it, which gradually solidi- 
fies, and, with the cutis that has been detached from the subja- 
cent tissue, forms a crust. By this process the former globular 
form of the node becomes flattened. If the crust is now re- 
moved, the surface of the exposed node is seen to be even 
more glossy than before, and more serous fluid of the kind al- 
ready mentioned exudes from it. This again dries and forms 
another thin crust, beneath which suppuration of the node 
goes on, finally resulting in an ulcer that penetrates into the 
cutis, corresponding in size to the former node. So long as 
the disorganization of the node continues, the crust will be 
soft and easy to detach. Gradually, however, the base of the 
ulcer begins to granulate, the crust becomes firmer, more ad- 
herent, but finally falls off, leaving a depressed, dark-brown 
scar. 

If the node that undergoes central molecular disorganiza- 



216 PATHOLOGY AND TREATMENT OF SYPHILIS. 

tion is of the subcutaneous variety, the skin covering it — and 
which, in conjunction with it, forms a tumor — becomes red. 
An inflamed swelling, more or less extensive according as it is 
composed of one or several conglomerated nodes, originates. 
The tumor, which at first is solid, gradually becomes doughy, 
and begins to fluctuate on palpation. The affected part of the 
skin finally becomes livid, attenuated, and bursts in one or 
more places, according as the tumor consists of one node or of 
an agglomeration of several, and a thin, purulent fluid then 
escapes. If the tumor was composed of one node only, the 
opening will rapidly become larger, and an ulcer that pene- 
trates to the very bottom of the former node will form. Its 
edges are steep, undermined, and its bottom is covered with 
dirty-looking matter. E"o zone or inflammatory areola is usu- 
ally to be seen around the ulcer. If there are several openings, 
the bridges of the skin between them gradually slough away, 
and a large ulcer forms, which is surrounded by a livid-red, 
undermined, cutaneous margin. The pus from the ulcer dries 
up, and forms a large or small, thin or thick, greenish-yellow or 
reddish-brown soft crust, which lies quite loosely upon the bot- 
tom of the cavity. While the crust of a superficial node that 
has undergone degeneration is somewhat larger than the node 
itself, in the deep variety, it is often smaller than the ulcer, 
lies beneath the skin, and is surrounded by a circular groove 
that separates it from the sharply outlined margins of the lat- 
ter. If granulations begin to sprout on the bottom of the 
ulcer, the crust becomes denser, and adheres more firmly. The 
ulcer seldom closes up by concentric contraction of the skin 
alone ; cicatricial tissue is almost always formed, and fills up 
the cavity. 

Ulcers which have formed in consequence of the disorgani- 
zation of the cutaneous and subcutaneous nodes may retain 
their round form till cicatrization has ensued. It very fre- 
quently happens, however, that a round spot on the margin of 
the ulcer cicatrizes in one direction, while sloughing goes on 
concentrically in another, and cicatrization gradually creeps on 
over the newly ulcerated space. Thus kidney-shaped, serpigi- 
nous ulcers may originate from circular sloughs. This serpigi- 
nous ulcer usually lasts a long time, and sometimes spreads 



SYPHILIS. 217 

over a large surface. But kidney-shaped ulcers may be pro- 
duced by the disorganization of cutaneous and subcutaneous 
nodes without having a serpiginous character. This is the 
case when the nodes are aggregated in a semicircle, and then 
undergo purulent degeneration. 

After the skin formerly occupied by the node has com- 
pletely cicatrized, it becomes attenuated, depressed, has a bluish- 
red or coppery color, feels hard to the touch, and desquamates. 
The cicatrix only becomes pale and soft when the proper treat- 
ment has been continued for a long time. It then ceases to 
desquamate, and its remarkably white color presents a striking 
contrast to the surrounding normal integument (atrophy of the 
discolored spot). The uppermost stratum of the cicatrix, which 
takes the place of the epidermal layer of the normal skin, has 
the appearance of straw-paper, and becomes wrinkled, as if it 
were too large for the cicatrix. In some cases, the gumma- 
cicatrices are not depressed, but, on the contrary, project even 
above the level of the skin. These scars have a keloid appear- 
ance, and, according to our experience, soon degenerate. In 
fact, only those scars resulting from ulceration of syphilitic 
nodes are likely to be permanent that have ceased to desqua- 
mate, are perfectly white, and not abnormally hard. 

Syphilitic nodes may appear on any part of the skin, but 
are usually met with in the face, especially on the forehead, 
the tip of the nose, and the lips. On the trunk, they seem to 
have a predilection for the region of the shoulders. They are 
very frequently found in the immediate vicinity of a joint, as 
also on the extensor surfaces of the extremities; further, at 
the sterno-clavicular and claviculo-acromial joints. On the leg, 
they develop generally on the anterior and internal surfaces. 
Occasionally we have even seen them on the palm of the hand 
and on the ear. This syphilide is generally confined to one or 
several of the places mentioned, and occurs in groups of two 
or three simultaneously. It is seldom seen scattered uniformly 
over the body, and even then the nodes do not appear on all 
the places at once. When occurring in groups, the nodes form 
oval, curved, or circular segments, which develop in the fol- 
lowing manner : A single node, remarkable for its size, or sev- 
eral nodes near each other, originate at a certain place on the 



218 PATHOLOGY AM) TREATMENT OF SYPHILIS. 

skin, and, as these begin to disappear, partly by absorption, 
partly by desquamation, new ones shoot up on their outskirts. 
The latter again may disappear in the same manner as the pre- 
ceding crop, and be succeeded by another, resulting in circles, 
of large or small dimensions. The nodules that form a circle 
are grouped more or less closely, or they coalesce so that the 
globular conformation of the individual tumors is no longer 
distinguishable. In some cases the nodules, especially those 
occurring in the face, are apt to be huddled together so closely 
that, collectively, they form a conglomeration like a cluster of 
grapes {syphilis racemiformis of the old writers). The origin 
of tumors resulting from the coalition of several nodules, on 
whose surfaces, however, the contours of the individual gum- 
mata are undistinguished, has been designated by some authors 
as lupus hypertrophicus syphiliticus. Like the dry nodes, the 
suppurating nodules also occur in groups, and are arranged 
in circles. Disintegrating gummata, which are so closely clus- 
tered together that they almost form one node, have been called 
by some lupus syphiliticus exulcerativus. That form in which 
the nodes, arranged in a semicircle, suppurate in a given direc- 
tion only, while cicatrization goes on toward the center, and 
new softening gummata constantly spring up at the periphery, 
has been termed lupus serpiginosus. The term lupus ought 
to be reserved for lupus vulgaris, and the suppuration of syphi- 
litic nodes alone should be spoken of in describing the disease 
under consideration. 

Of all the syphilides, nodular syphilide runs the slowest 
course, and is the most obstinate to treat. Not only do new 
gummata spring up on various parts of the body, despite treat- 
ment with mercury and iodine, but they also form on those 
places where some of them had already existed and disappeared. 
The earliest period in which we saw syphilitic nodes appear 
was four months after infection had taken place ; the latest pe- 
riod twenty years. Other syphilographers mention even thirty 
and forty years. Of all the syphilitic diseases of the skin 
which came under our observation, specific gummata were the 
least frequent. 

Being the result of a later phase of the syphilitic disease, 
nodular syphilide never appears in conjunction with those phe- 



SYPHILIS. 219 

noniena that are peculiar to the earlier manifestations. At the 
most, a few ecthynia-pustules or rupia-ulcers may be found 
associated with it. The presence of moist papules may be 
excluded a priori with the utmost safety. The most frequent 
complications of the tubercular syphilide are orchitis syphi- 
litica, extensive disease of the fibrous structures, ulcerations 
and malformations of the nasal and pharyngeal walls, syphilitic 
disease of the liver and of the brain, 

Syphilitic nodes or gummata always indicate a far-advanced 
syphilitic affection, and at the same time they are the final re- 
sults of the morbid processes. They not only occur on the sldn 
and mucous membrane, but in other tissues and organs of the 
body. A specific cutaneous node is, therefore, an index for 
the diagnosis of syphilitic diseases of the viscera, brain, and 
nerves. Hence it is also clear how a nodular syphilide may 
essentially alter the prognosis. It may also be added that the 
disease may relapse after many years of quiescence and appar- 
ent cure. "When syphilitic cutaneous nodes undergo degen- 
eration, the suppuration of coexisting inflammatory products 
— for instance, in the periosteum, and, in consequence thereof, 
caries and necrosis of the affected portions of the bones — may 
be apprehended. Furthermore, ulcerating nodes may cause 
terrible mutilation and disfigurement with frightful rapid- 
ity. Thus, one ala naris, a part of an eyelid, or a lip, may 
be destroyed. In like manner, the scars which result from 
the ulceration of the syphilitic node constitute unmistak- 
able evidence of the character of the disease that preceded 
them. 

Of the specific diseases of the skin, lenticular papular 
syphilide alone can be mistaken for the nodular syphilide — an 
error that is of no importance as regards the treatment, but 
altogether different as regards prognosis. The smaller size of 
the papule, the site, the total absence of pain, the much earlier 
appearance of this eruption and its profuseness, the simulta- 
neous presence of moist papules on the skin and on the mucous 
membrane, as also its entire course, will be more than suffi- 
cient to guide the physician in differentiating the two cutane- 
ous diseases that were engendered by the same morbid condi- 
tion of the blood. 



220 PATHOLOGY AND TREATMENT OF SYPHILIS. 

Of the non-syphilitic diseases of the skin, molluscum se- 
baceum and fibrosum, acne rosacea tuberosa, rhino-scleroma, 
lupus vulgaris, and especially carcinoma of the cutis, are the 
only ones that can be mistaken for nodular syphilide. 

The molluscum differs from specific gummata by the con- 
striction at its base, as it is more or less pediculated in most 
cases ; but even the non-pediculated molluscum sessile affords, 
by the plate-like depression at its highest point, by its soft- 
ness, and by the inspissated sebaceous secretion, which may be 
squeezed out on puncture, sufficient data to prevent an error in 
diagnosis. Molluscum fibrosum is recognized by its firmness 
and painlessness, and also by its persistence. 

The kernels of acne rosacea tuberosa differ from syphilitic 
nodes of the face and nose by the fact that they are not as 
smooth and glossy as the latter, being almost always uneven. 
Furthermore, there is a total absence of the dilatations of the 
capillary vessels in the vicinity of the syphilitic node, and its 
brownish color is distinctly outlined, while the dark-red color 
of acne rosacea merges gradually into the normal carnation of 
the skin. The skin adjacent to the specific node is not so hy- 
pertrophied as in acne rosacea of severe grade. Lastly, syphilitic 
gummata frequently undergo degeneration, and in this manner 
often destroy part of the nose. This never happens in acne 
rosacea. 

The greatest difficulty in reference to the differential diag- 
nosis will be occasioned by the neoplastic growth which Hebra 
has called rhino-scleroma, because, like the nodular syphilide, 
it has the tendency to destroy the soft parts of the nose and 
of the uvula; and, moreover, also runs a protracted course. 
The absence of the phenomena preceding and accompanying 
syphilis; the stony hardness; the diminished permeability of 
the nasal passages ; the slow destruction of the soft parts of 
the nose, while the bony structure remains intact ; the inef- 
ficiency of antisyphilitic remedies ; finally, the history of the 
disease, preceded by a trauma of the nose— will enable us to 
exclude syphilis, and suspect that the neoplasm is a rhino-scle- 
roma. 

The following pathogenetic and morphological signs may 
be pointed out for the purpose of distinguishing lupus vul- 



SYPHILIS. 221 

garis from confluent and sloughing nodular syphilide : Lupus 
vulgaris develops generally before the occurrence of puberty, 
while specific gummata are usually met with in persons of 
more advanced years. The destruction of syphilitic nodes goes 
on more rapidly than that of lupus tubercles. Lupus-spots are 
always surrounded by an active zone, which gradually fades into 
the normal shin, and not infrequently forms a phlegmonous 
swelling. Specific confluent nodes and ulcers resulting from 
their disintegration have very little or no inflammatory areola 
around them. The tubercles and ulcers of lupus vulgaris are 
painless when touched, while marked pressure on syphilitic 
gummata causes severe pain. Lupus vulgaris, as a rule, does 
not attack the bony part of the nose, while gummata of the 
nose generally begin with ozsena syphilitica. Lupus vulgaris 
usually heals by leaving radiating scars ; syphilitic nodes leave 
depressed scars. It is often difficult to decide whether, in a 
given case, we have to deal with lupus vulgaris or hereditary 
lues ; but the course and the effects of the remedies, and still 
more the fact that in the latter affection the soft palate, as a 
rule, is ulcerated or adherent to the posterior pharyngeal wall, 
will often furnish a key to the diagnosis. 

Multiple carcinoma of the skin and sarcoma melanodes 
present great similarity to nodular syphilide, which, like them, 
is scattered over the integument. However, carcinoma and 
sarcoma tumors never have the spherical form of gummata ; 
they are flat and smooth. They usually occur in large num- 
bers on the trunk ; a few solitary tumors only may be met 
with in the face and on the extremities. In color they are 
bluish or brownish-red, whereby the skin acquires a marbled 
appearance. Of course, no carcinomatous or sarcomatous tu- 
mors disappear by absorption ; and equally rare is it for a car- 
cinomatous tumor to ulcerate speedily ; for long before this 
takes place cancerons growths will have formed in some of the 
viscera of the body, undermined the system and produced death. 
At the autopsy multiple carcinomatous tumors are found in 
the form of small medullary cancers, white, or entirely black 
in color (cancer melanodes), or only sprinkled with black spots ; 
sarcoma melanodes appears as an incomplete fibromatous neo- 
plasm, profusely tinted with dark dots. 



222 PATHOLOGY AND TREATMENT OF SYPHILIS. 

The So-called Pigment Syphilis. 

Syphilitic efflorescences, especially gunimata, pustular syphi- 
lids, and the primary lesion, usually leave intensely discolored 
spots, which last for a long time. These discolorations disap- 
pear when the syphilis is entirely cured, and are sometimes suc- 
ceeded by a permanent blanching of that part of the skin pre- 
viously occupied by the specific ulcer. "We know of no syphi- 
lide that manifests itself only by the appearance of primary 
discolorations of the skin. 

Syphilitic Affections of the Hair. 

Syphilis, like some of the acute febrile affections, often 
causes diseases of the hair, and the persons attacked by it be- 
come bald — sometimes temporarily, in other cases, permanent- 
ly. The hairs that are about to fall out lose their luster, and 
the patient, on combing or brushing himself, or by running 
his fingers through the hair, causes many of them to fall out. 
Thus, the capillary covering of the head becomes diminished, 
and the scalp is more or less exposed. Marked baldness of the 
head becomes evident when the defluvium capillorum has con- 
tinued for a long while. Various forms of baldness are dis- 
tinguished according to the location, extent, and severity of 
the loss of hair. Thus, when the hairs begin to fall from the 
crown of the head, it is called phalacrosis ; from the back of the 
head, opistophalacrosis ; unilateral baldness, hemiphalacrosis ; 
and if the falling out of the hairs occur in serpentine lines, 
ophiasis. As a result of syphilis, not only the hairs of the head 
fall out, but also the eyelashes, eyebrows, the beard, the hair 
of the pubis, and axilla. The morbid process that causes the 
falling out of the hair is due, according to our researches, to the 
shrinking of the cells and granules that constitute the hair- 
pulp. The hair in the follicle, therefore, dies, and would fall 
out, were it not retained in its sheath at the root. Finally, 
however, the root-sheath, too, is cast off in the form of minute 
scales, the hair loses its hold and drops out, or it falls out with 
its root-sheath. 

The falling out of the hair, as a rule, begins a few days after 
the eruptive fever has been ushered in, and it is not only ar- 



SYPHILIS. 223 

rested by curing the underlying disease, but the hairs speedily 
grow again. If the treatment has been inappropriate, the 
defluvium capillorum may recur several times ; the plentiful 
growth of the hair after each falling out may, in fact, be 
looked upon as a favorable prognostic omen. Sex, age, and 
season of the year exercise no modifying influence over the 
origin of alopecia syphilitica ; but the growth of the hairs is 
so far affected by age, that in young persons it takes place 
more quickly, and is more complete, than in those of advanced 
years. The falling out of the hairs usually precedes and ac- 
companies early syphilides. 

Syphilis, however, sometimes causes a circumscribed bald- 
ness {alopecia areata) by suppuration and destruction of the 
hair-follicles. This happens, especially, in consequence of con- 
fluent, impetiginous syphilides or deep ulcers of the scalp, in 
the beard, or on other places. No hairs can grow upon cica- 
trices that form here. 

In order to distinguish alopecia syphilitica from alopecia 
vulgaris prematura and senilis, it is necessary, in addition 
to the antecedents and concomitants, to take into consideration 
the facts that in the latter affection the hairs only fall out on 
the crown and anterior part of the head, while those on the 
rest of the scalp remain ; that in calvities senilis or prematura 
the skin is remarkable for its luster and smoothness, because 
in these diseases the hair and sebaceous follicles disappear en- 
tirely ; in alopecia syphilitica, on the contraiy, they are not 
only not destroyed, but even generate an increased amount of 
sebum. The deposit of sebum upon the smooth and bald skin 
gives it a scaly appearance. 

Alopecia produced by herpes tondens (pliyto-alopecia, ac- 
cording to Gruby) may readily be mistaken for the circum- 
scribed alopecia resulting from the suppuration of syphilitic 
efflorescences. The former disease of the hair, however, is 
distinguished by the fragility of the hairs, and, above all, by the 
presence of a cryptogamous parasite. 

Syphilitic Disease of the Nails. 

The nails, like the hair, to which they are histologically 
akin, suffer from syphilitic morbid alterations, which manifest 



224 PATHOLOGY AND TREATMENT OF SYPHILIS. 

themselves in an inflammatory affection and ulceration of the 
skin in immediate contact with the nails. The latter are sec- 
ondarily destroyed, and cast off — -paronychia syphilitica — or 
the texture of the nail undergoes certain alterations without 
the parts around it becoming in any way affected — onychia 
syphilitica. 

(a) Paronychia syphilitica appears either as an inflammation 
of the nail-groove — paronychia syphilitica lunularis — or as an 
inflammation of the fissures of the nail— paronychia syphilitica 
lateralis. 

Paronychia lunularis begins with a moderate degree of swell- 
ing and redness of the cutaneous structure bordering on the 
root and lunula of the nail. The swelling gradually increases, 
has a dull, reddish color, is semilunar in shape and painful to 
the touch, and covers the lunula more or less. In some cases 
this swelling becomes pale and subsequently undergoes resolu- 
tion. In most cases, however, the epidermal covering of the 
swelling under consideration is raised up by a sero-purulent or 
sanious fluid, resulting in a sloughing wall which surrounds 
the root of the nail. After the slough has been cast off, an 
ulcer will be found which may destroy the matrix of the nail, 
and then gradually extend to the lateral fissures, being, in 
fact, a continuation of the morbid process of the root of the 
nail. When the slough forms, the nail loses its transparency, 
becomes greenish, and finally rough and brittle. The more 
the ulcer encroaches upon the bed of the nail, the more the 
nail will be raised up from its bed ; and, finally, it is cast off, 
or is gradually macerated by the secretion of the ulcer and dis- 
solved. In most cases a new nail grows after the old one has 
fallen off ; but it is quite sure to be crooked and ungainly. 
The inflammatory process that brings about the destruction of 
the matrix and the bed of the nail, constitutes, according to 
our researches, a locally modified ecthyma pustule. We have 
seen, in fact, in most cases of severe pustular syphilides, ulcer- 
ating paronychia, while in the dry syphilides paronychia usu- 
ally disappears by absorption. 

Paronychia lateralis accompanies papular syphilides. In 
one of the lateral fissures of the nail, a moist papule forms, 
slowly extends under it, and, by increasing in size, gradually 



SYPHILIS. 225 

raises, and, at the same time, enucleates it. Having been 
disturbed from its position, the nail soon displays the textural 
lesions already described. If the papule under the nail under- 
goes molecular destruction, the latter will gradually become 
soft, and then be cast off. 

Paronychia syphilitica may develop upon the fingers ; but 
it occurs by preference on the toes. At any rate, the pressure 
of the shoe seems to foster its production. As a rule, it is 
met with only on one finger or one toe. 

(b) Onychia syphilitica displays various grades. In the low- 
est grade the diseased nail has a rosy color, its gloss is gone, 
and small white spots, as big as a pin's head (flores or mendacia 
unguium or lies of the English writers) originate upon it. They 
are due to the imperfect hardening of the cells that form the 
substance of the nail (Yalentine), and irritation of the matrix 
seems to be at the bottom of it. If the general syphilitic dis- 
ease is treated early and successfully, the nails will subsequent- 
ly have no white spots. The succeeding healthy portions are 
then separated from the diseased portion by a white line ; but 
if the specific disease continues, the nail becomes more and 
more opaque, rough, and brittle, and distorted on its free mar- 
gin, where small fragments may be broken off. At the same 
time its root is gradually detached from the matrix, and is suc- 
ceeded by a nail that is likewise diseased. 

The affection of the tissue under consideration, which, in 
contradistinction to paronychia suppurativa, .we would call ony- 
chia sicca, develops mostly in cases of pronounced and per- 
sistent psoriasis palmaris et plantaris diffusa syphilitica. It gen- 
erally attacks all the nails of the fingers as well as of the toes. 

"We will only speak here of the various non-syphilitic af- 
fections of the nail which might be mistaken for the specific 
variety, and, not being able to point out any distinguishing 
pathognomic signs, we are compelled to refer the reader to the 
fact that the etiological factor of any disease of the nail can 
only be ascertained by the previous and present history. 

The non-syphilitic diseases of the nail are either of local 

nature, or originate in consequence of a general disease. 

Thus, paronychia ushered in by suppuration of the nail-fissures, 

especially on the big toes, often originates from pressure of a 

15 



226 PATHOLOGY AND TREATMENT OF SYPHILIS. 

badly fitting shoe that causes crowding of the lateral margin 
of the nail into the flesh. In consequence of eczema of the 
nails of the fingers and of the toes, a paronychia ending in loss 
of the nail likewise is sometimes produced. Scrofula, also, not 
infrequently causes an inflammatory bulbous hypertrophy of 
the nails ; still, in this case suppuration of the hypertrophied 
part seldom ensues. Further, it is said that in persons who 
suffer from valvular disease of the heart an onychia sicca occurs 
(Wunderlich), which is known to authors under the name of 
defoedatio, or scabrities unguium, and is distinguished by the 
fact that the nail not only becomes rough, opaque, and brittle, 
but undergoes hypertrophy, especially on the free margin, and 
acquires a color similar to the mold on cheese (cheesy nail). 

Syphilitic Affections of the Mucous Membranes. 

Next to the common integument, syphilis avails itself of 
the mucous membranes upon which to locate its morbid lesions. 
It manifests itself upon these structures under three varieties, 
namely : 

(1) Diffused erythema. 

(2) Papular inflammatory foci. 

(3) G-ummous, ulcerating nodes. 

Pustular efflorescences in consequence of syphilis never oc- 
cur upon mucous membrane. 

(1) Syphilitic Eetthema of the Mucous Membrane ; Syphi- 
litic Catarrhal Inflammation; Erythema Syphiliti- 
cum Membrane Mucosa. 

Syphilitic erythematous affection of the mucous membrane 
is seen in the form of a diffused, sharply defined, peculiarly 
livid color over extensive portions of the mucous membrane. 
It may disappear without causing the least textural lesion, and 
subsequently return ; but it may also produce such lesions as 
will leave the epithelium upon the affected places opaque, or 
they are cast off here and there, resulting in small erosions. 

While in some places syphilitic erythema will produce a 
sensation of dryness of the mucous membrane (erythema of 
the palate and of the posterior wall of the fauces), on other 
places it supervenes with anomalies of secretion of the affected 



SYPHILIS. 227 

part. The disease always begins with a diminished degree of 
secretion of the mucous membrane and the sensation of. dry- 
ness, but in the course of the malady so much mucus is se- 
creted that it amounts to a real blennorrhagia ; or even actual 
follicular suppuration, syphilitic catarrh, or snuffles, syphilitic 
vaginal and preputial gonorrhoea, and follicular ulceration of 
the tonsils, may ensue. The swelling of the syphilitic, ery- 
thematous mucous membrane generally is slight, being very 
marked on certain places only (uvula, tonsils, labia minora). 
In consequence of the swelling, certain tubular tracts of mu- 
cous membrane — for instance, the lachrymal duct, nasal and 
ear passages, and the larynx — may become narrowed, producing 
serious functional disturbances in the conduction of sound and 
of the tears, as also in speaking. 

The specific catarrhal affection of the mucous membrane 
generally is a symptom of one of the first phases of syphilis, 
and is therefore always accompanied by early morbid phenom- 
ena in other tissues and organs. It occurs either as a solitary 
manifestation of syphilis, or it is only the forerunner of pap- 
ules of the mucous membrane which are in course of forma- 
tion or nodular exudations, or it appears in company with the 
latter only, and remains as their sequelae. Certain external and 
internal conditions promote syphilitic catarrhal affection of 
some regions. Thus persons who smoke or chew tobacco to 
excess, those who are exposed to unfavorable conditions of 
the weather, or who often suffer from angina catarrhalis vul- 
garis, and tuberculous patients, are more frequently attacked 
by angina catarrhosa syphilitica than others. Catarrh of the 
vulva seems to be fostered by frequent intercourse ; congenital 
phimosis favors the production of balanitis, etc. 

Syphilitic erythematous affection may relapse like other 
specific affections ; syphilitic catarrhal affection of the isthmus 
faucium, in fact, relapses most frequently. As a rule, when a 
catarrhal affection relapses, papular inflammatory foci will again 
form on the same places. 

(2) Syphilitic Papules on the Mucous Membkane. 

The mucous membrane papule does not always, nor on all 
places, possess the nodular shape of its sister-efflorescences on 



228 PATHOLOGY AND TREATMENT OF SYPHILIS. 

the common integument. As a rule, it barely rises above the 
level, of the mucous membrane. But those papules that are 
situated upon places of the mucous membrane where the papil- 
lae are markedly developed — for instance, on the cup-shaped 
follicles of the sense of taste at the root of the tongue — have a 
good opportunity to develop into the papular type of the dis- 
ease. Like the syphilitic papule of the common integument, 
the specific papule of the mucous membrane is caused by cel- 
lular infiltration of the papillae, or into and around the follicles 
of the mucous membranes. 

A mucous - membrane papule develops in the following 
manner : A circular spot on the mucous membrane as big as a 
lentil or pea becomes red and rises somewhat above the level 
of the membrane, from which, in case the mucous membrane 
is not catarrhally reddened, it will be distinguished by its livid 
color. Early and appropriate treatment may cause complete 
absorption of papules that are developing. But, if left un- 
treated, and if the pernicious effects that tend to promote their 
development continue to exercise their iniluences upon the 
diseased mucous membrane, the epithelial layer will become 
opaque, acquire a milky whiteness, or the color of mother-of- 
pearl {plaques opalines of the French writers). These opaque 
spots on the mucous membrane look as if the latter had been 
penciled with a solution of nitrate Of silver. The pearly- white 
epithelial layer on the mucous-membrane papule may be cast 
off, in which case the efflorescence, deprived of its epithelial 
cells, will resemble an intensely red erosion that bleeds readily. 
If several papules denuded of their epithelium-cells are situ- 
ated closely together on some place of the mucous membrane, 
the latter will become dotted with red spots, as is often the 
case on the upper surface of the tongue. Even in this stage, 
the papular efflorescence may disappear entirely, or undergo 
still further alterations. These papules, like those of the com- 
mon integument, may, in rare cases, by the sprouting of the 
papillae, grow into conical, condylomatous products, having an 
irregular caruncular appearance — a condition that is frequently 
met with on the uvula and under surface of the tongue. Most 
frequently it undergoes molecular degeneration, resulting in 
whitish-gray patches, with rough, shaggy borders (syphilitic 



SYPHILIS. 229 

aphthae of the old writers). If the mucous-membrane pap- 
ules that have undergone molecular degeneration are situated 
closely together, or if they coalesce, the affected spot will ac- 
quire a diphtheritic appearance. If a part of a papule covered 
with molecular detritus is situated upon the mucous mem- 
brane, and the other part on the common skin (moist papule), 
the detritus upon the latter will dry up and form a dirty, 
brownish-colored crust, while that upon the mucous mem- 
brane will remain in a pultaceous condition. Such biformed 
papules are frequently found at the angles of the mouth, on 
the margins of the labia majora, at the anus, etc. The longer 
the destructive process in the papule lasts, and the longer the 
injurious external causes continue to exercise their evil effects, 
the deeper the sloughing will extend ; and round, straight, or 
S-shaped fissures of the mucous membrane {rkagades) will 
originate. They are situated upon a hard base, and sometimes 
surrounded by a red wall. These clefts of the mucous mem- 
brane are frequently found on the borders of the tongue, espe- 
cially when they are constantly irritated by rough fragments 
of teeth, and in patients addicted to the use of tobacco ; at 
the anus in consequence of difficult defecation. They are, 
however, also met with on the upper surface of the tongue in 
inveterate relapsing syphilis. 

The papules are observed most frequently on the mucous 
membrane of the mouth, uvula, fauces, and the tracts leading 
from these parts. They originate here mostly on the mucous 
membrane of the tonsils and of the lips, especially at the angles 
of the mouth, on the uvula, and in the sinus between the an- 
terior and posterior pillars of the palate ; next in order of 
frequency, on the lip, edges, and roots of the tongue ; then, 
on the mucous membrane of the cheeks, particularly near the 
angles of the mouth. Sometimes they develop on the vocal 
cords, and in the sinus Morgagni of the larynx ; rarely on the 
posterior pharyngeal wall and in the Eustachian tube. They 
occur less frequently on the mucous membrane of the vagina, 
on the cervix and os uteri, at the meatus and rectal mucous 
membrane of both sexes, on the internal surface of the pre- 
puce in the male, and, lastly, on the mucosa of the nasal pas- 
sages, especially of the nares and of the cartilaginous portion 



230 PATHOLOGY AND TREATMENT OF SYPHILIS. 

of the septum. Mucous -membrane papules occur either iso- 
lated or in groups. 

Although they are ushered in with acute inflammatory 
phenomena, such as pain and erythematous redness' of the skin 
in the vicinity, still they soon assume a protracted course, ob- 
stinately resisting the most judicious local and .general treat- 
ment for months ; or they occasionally disappear, but soon return 
again. As soon as resolution sets in, the opacity and thicken- 
ing of the epithelial covering begin to disappear, while on 
the disorganized papule the molecular detritus grows less, and 
new bluish epithelium-cells sprout up. In confluent papules 
the healing begins in the center, and gradually progresses to- 
ward the periphery. The vegetations that sometimes form 
upon the papules disappear by shrinking. Even ulcerating 
mucous-membrane papules leave no noticeable scars. 

Ulcerating papules of the tongue and lips interfere greatly 
with mastication and speaking. Papules on the mucous mem- 
brane of the tonsils hinder the process of swallowing very 
much. Those in the Eustachian tube cause ringing in the ears, 
and temporary hardness of hearing. Patients suffering from 
sloughing papules on the tonsillary mucous membrane have a 
foul breath. Papules on the mucous membrane of the mouth 
cause an increase of the flow of saliva. Ulcerating papules at 
the commissures of the lips often prevent the mouth from 
being opened properly. Nurslings are hindered in sucking 
the breast when the papules are situated on the mucous mem- 
brane of the lips. Papules in the rectum interfere with defe- 
cation, and, like those on the vulva, cause pain in walking. 
In cases of ulcerating papules on the mucous membrane of the 
lips, the submaxillary glands may become inflamed ; and in 
consequence of similar eruptions in the vagina the labia majora 
become (edematous, and cause indolent hypertrophy of the 
inguinal glands. Papules on the mucous membrane of the 
vagina, uterus, and the meatus, often cause slight blennor- 
rhagic discharges from these parts. Sloughing papules on the 
mucous membrane of the septum nasi may destroy the peri- 
chondrium of the septum, and cause the tip of the nose to sink 
in (sheep-nose, or nez de mouton, of the French writers). 

Papular syphilides and the morbid lesions occurring with 



SYPHILIS. 231 

them in other organs usually accompany mucous-membrane 
papules. But erythematous and pustular syphilides may also 
coexist with the affection under consideration, and confluent 
impetiginous syphilide is especially apt to be associated with 
suppurating mucous-membrane papules. Sometimes this form 
of papule is the only evidence of syphilis, especially of the 
relapsing form. 

Mucous-membrane papules originate as a result of acquired 
as well as of congenital syphilis ; however, certain conditions 
may favor their formation. Thus, uncleanliness of the female 
genital organs and of the rectum will promote their develop- 
ment. Inveterate smokers, glass-blowers, buglers, and others 
get papules on the tongue and lips, places that are mostly irri- 
tated by the mouth-piece of the pipe and of the wind instru- 
ment. 

The papules relapse even more frequently than those on 
the common integument, mainly, however, in the form of 
scattered or confluent pearly-white epithelial opacities of the 
tip of the tongue and mucous membrane of the lips, either 
shortly after an apparent recovery had been achieved, or even 
after the lapse of a year. Eelapsing mucous-membrane pap- 
ules run a much more obstinate course than the primary ones.. 

(3) The Syphilitic Node or Gumma of the Mucous Mem- 
brane. 

A gumma develops in the mucous membrane, and in the 
submucous tissues in the same manner as in the cutis and subcu- 
taneous tissue. But nodes of the mucous membrane are flatter, 
less prominent, and less sharply defined, hence more like dif- 
fused infiltrations. They may become as big as a pea or bean. 
Histologically and morphologically, gummata of the mucous 
membrane and of the skin are perfectly identical, and the for- 
mer, like the latter, may disappear by absorption or degen- 
erate. In the latter event, deep ulcers with hypertrophied 
borders are formed, because the nodes break down from within 
outwardly. The course of the mucous-membrane nodes is as 
protracted as that of gummata of the general skin. The ulcers 
that originate from their destruction do indeed heal some- 
times in robust persons, but, as a rule, they grow larger both in 



232 PATHOLOGY AND TREATMENT OF SYPHILIS. 

size and in depth, and give rise to horrible disfigurements and 
leave permanent deformities, by destroying portions of an 
organ, for instance, the uvula or a part of an eyelid ; cause 
caries and necrosis of adjoining bones, such as the vomer ; or, 
finally, perforation of the tissues, for example, the palate. The 
ulcer usually heals by contracting cicatrices, causing adhesions 
to form. Tubular organs, such as the pharynx, larynx, tra- 
chea, lachrymal sac, intestines, rectum, and urethra may be- 
come constricted. 

Syphilitic nodes, like other specific affections of the mucous 
membrane, most frequently originate upon the mucous mem- 
brane of the mouth, especially on the tonsils, on the lips, on 
the velum palati, on the posterior wall of the fauces, borders 
of the tongue, on the lips, and on the hard palate. However, 
a gumma may also develop in the pharynx, in the sinus Mor- 
gagni of the larynx, and in the upper and posterior regions of 
the nasal passages. It occurs less frequently on the mucous 
membrane of the rectum and the cervix of the uterus, and still 
more rarely on the mucous membrane of the male urethra. 

In most cases specific nodes of the mucous membrane and 
of the submucous tissue are the only perceptible external mani- 
festations of an inveterate- syphilitic disease. In other cases, 
however, there are also present those syphilitic morbid lesions 
in other tissues and organs that coexist with gummata of the 
skin and of the subcutaneous tissues. 

Like gummata of the common integument, nodes of the 
mucous membrane, and especially those emanating from the 
submucous tissue, are not only the result of acquired syphilis, 
but frequently accompany that kind of congenital syphilis that 
first appears in youth. 

These nodes relapse just as often as gummata of the integu- 
ment, appearing months and sometimes years after the disease 
was apparently cured completely. A relapsing specific node 
may even recur upon the scar of a previous node. 

In the vast majority of cases the manifestations of syphilis 
of the mucous membrane are confined to those regions that are 
visible ; for instance, the mucous membrane of the nose, mouth, 
and fauces and their ramifications, the larynx and pharynx, the 
rectum and genital organs of both sexes. 



SYPHILIS. 233 

Syphilis of the Mouth and Fauces. 

In regard to syphilis of the mucous membrane of the lips 
and of the cheeks, the reader is referred to what was said in the 
general part on syphilis of the mucous membrane. The mu- 
cous membrane covering the structures that constitute the isth- 
mus faucium becomes affected earliest and oftenest. We dis- 
tinguish three kinds, namely, angina syphilitica erythematosa, 
papulosa, and gummosa. 

Angina syphilitica erythematosa is distinguished from the 
ordinary inflammations of the fauces and from other specific 
affections of these parts by the facts that the entire part of the 
mucous membrane affected (soft palate, uvula, palatine arch, 
and tonsils) is livid in color ; on both sides this terminates at 
the line separating the soft from the hard palate. Except that 
the uvula is sometimes elongated, no textural alteration can be 
detected in the diseased mucosa, and consequently the patients 
seldom complain of anything more than dryness of the fauces 
and slight difficulty in swallowing. 

Syphilitic erythema of the fauces will disappear spontane- 
ously if the patient takes proper care of himself. But if the 
pernicious causes continue, such as using tobacco to excess, it 
will extend to the Eustachian tube on the one hand and into 
the larynx on the other, and will cause noises and ringing in 
the ears (tinnitus aurium), and hoarseness (raucedo syphilitica). 
It very seldom becomes aggravated to a condition of actual f ol- 
licular suppuration. 

Angina syphilitica erythematosa very often accompanies 
the eruptive fever ; in fact, it serves to make the symptoma- 
tology of syphilis complete, and consequently almost always 
disappears when the febrile symptoms have disappeared. In 
other cases it accompanies every syphilide of the early phases 
of the disease and lasts till the eruption has undergone resolu- 
tion, or disappears and returns while the latter lasts. But it 
may return even after all the other symptoms have been ap- 
parently cured, in case the latter reappear. Angina syphilitica 
erythematosa per se admits of a favorable prognosis ; but if it 
lasts a long while or repeatedly returns, it will excite appre- 
hension that the isthmus faucium is so enfeebled that, in case 



234 PATHOLOGY AND TREATMENT OF SYPHILIS. 

of a relapse, especially in debilitated persons, it will become 
the site of some grave lesion. 

Angina syphilitica papulosa may or may not be attended 
by catarrhal swelling of the structures constituting the isthmus 
faucium. In the latter case no mucous-membrane papules in 
the isthmus become perceptible till they cause, in consequence 
of their disorganization, difficulties in swallowing. Those pap- 
ules that are situated on the anterior surface of the velum and 
anterior arch of the palate generally are the best developed, 
while those on the tonsils are only rudimentary in form. 
Those situated on the anterior arch of the palate, on the ton- 
sils, and anterior surface of the posterior arch of the palate, 
usually undergo degeneration very quickly, causing circular 
turgid spots on the mucous membrane, or, where the degenera- 
tion penetrated deeper, a diphtheritic pseudo-membrane will be 
poured out upon the affected part of the mucous membrane. 
This pseudo-membrane, which consists of molecular detritus, 
may gradually disappear and normal epithelium-cells then 
form, or it is cast off and the places then present the appear- 
ances of eroded ulcers. New papules may form on the periph- 
ery of these ulcers, which likewise subsequently degenerate, 
and the ulcers on the arch of the palate may spread in such a 
serpiginous manner as to extend upon the uvula in one direc- 
tion and hard palate in the other. 

Sometimes conical condylomata form upon the papules 
that are situated upon the uvula. If opaque or ulcerating 
papules occur on the tonsils, the latter will swell up to such a 
degree as to become flattened by mutual compression. The 
bolus of food, in passing over the ulcerating papule, rubs off 
the diphtheritic molecular coating, and the abraded, swollen 
mass, bereft of epithelium, and bleeding at the least touch, 
may be mistaken by inexperienced physicians for a deep ab- 
scess of the tonsil. Angina syphilitica papulosa sometimes 
causes severe temporary impairment of hearing, a condition 
which is readily explained by the fact that in the affected cases 
papules occur in the Eustachian tube. 

Mucous-membrane papules constitute the most frequent 
syphilitic affection of the isthmus faucium, and occur in con- 
junction with all those phenomena which are associated with 



SYPHILIS. 235 

moist papules of the common integument. They, too, heal by 
resolution, without producing any perceptible cicatrices, and, 
for that reason, the prognosis of angina syphilitica papulosa is 
not less favorable than that of angina syphilitica erythematosa. 
The papules of the isthmus faucium are not infrequently the 
harbinger of a series of phenomena of a renewed outbreak of 
syphilis. 

Angina syphilitica gummosa very often attacks the tonsils, 
soft palate, and uvula. Generally, several nodes form simul- 
taneously in the tonsils, whereby the latter may swell up to 
such a degree as to come in contact with each other, and the 
uvula placed between them, which, like the palate, is not only 
affected with catarrhal inflammation and elongated, but in ad- 
dition becomes constricted and flattened. It is remarkable 
that the tonsils cause comparatively little pain, even during 
the act of deglutition, but they alter the voice so that it sounds 
hollow and dull, as if there were a foreign body in the mouth. 
On the other hand, the enlarged tonsils produce deafness, or at 
least hardness of hearing, by compressing the posterior arch of 
the palate against the fauces, and thus occluding the Eusta- 
chian tube. 

At the beginning of the disease the tonsils present a smooth 
but hyperaemic appearance ; gradually, however, the physiog- 
nomy of these glands changes according as softening and sup- 
puration or absorption and shrinking of the nodes take place. 
In the first case, one or more excavations, depending upon the 
number of nodes, originate. These will display lardaceous 
bases, varying in size from a pea to a bean, and may coalesce. 
The absorption of the nodes formed in the tonsils is attended 
by repeated congestion of the entire gland. Every time an 
attack of congestion ensues, the minute free glandular acini 
secrete a viscid mucus, and remain swollen and catarrhally 
affected, while the intervening places that harbor the nodes 
shrink. As a result of this process, the tonsils display a carun- 
cular, uneven surface, and are intersected by whitish stripes, 
consisting partly of cicatricial tissue, and partly of proliferat- 
ing connective tissue. If these hypertrophied tonsils are extir- 
pated, the wounds will suppurate for a long while. 

The development of a syphilitic node on the soft palate is 



236 PATHOLOGY AND TREATMENT OF SYPHILIS. 

likely to escape detection by the unaided eye for a long time, 
because it is generally met with on its posterior surface alone. 
The patient only complains of an unpleasant sensation in the 
velum and difficulty in swallowing. The velum is livid and 
painful when touched ; the tonsils, the arches, and the uvula 
are oedematous. Suddenly, to the great terror of the patient, 
and often of the physician likewise, perforation of the palate 
takes place. To avoid being taken by surprise, by the occur- 
rence of such an incident, the physician should never neglect, 
in these cases, to use the rhinoscope early and often, and to 
palpate the posterior surface of the palate with his finger. 
The opening may be of variable dimensions, and situated on 
any part of the velum. If it is situated near the free border 
of the palate, neither the voice nor deglutition will be affected. 
But if the perforation has taken place near the hard palate, a 
nasal or snuffling voice will result, and the food, especially 
fluids, will run out at the nose. The more intensely marked 
the inflammatory redness, and the more the vicinity of the 
perforated place is infiltrated, the greater the probability that 
the ulcer is progressing. But if the redness and swelling of 
the borders of the ulcer disappear under general and local 
treatment the aperture will gradually contract and cicatrize, 
leaving a minute, generally oval opening, which causes the pa- 
tient no inconvenience whatever. 

The gumma occurs more frequently on one of the lateral 
angles, which the palate forms with the uvula, than on the 
posterior surface of the velum. If such a patient is requested 
to pronounce the vowal a, it will be seen that the uvula does 
not contract, by becoming twisted upon itself in a vermiform 
manner, but is bent like a hook toward the affected half, be- 
cause one of the parallel azygos muscles has lost its power of 
contraction. If the node undergoes disorganization, a deep 
abscess originates, which may ultimately slough away the en- 
tire uvula, or leave it hanging by a thin pedicle. If the slough- 
ing of the uvula is arrested by early and successful treatment, 
a contracted cicatrix will originate, resulting in a permanent 
curvature of the uvula. A total loss of the latter neither 
affects the voice nor deglutition ; indeed, in consequence of 
syphilitic affections of the fauces, certain morbid alterations 



SYPHILIS. 237 

may ensue which cause the entire destruction of the uvula, 
and yet give rise to no inconvenience whatever. Thus, it may 
happen that when the posterior surface of the velum palati 
and the posterior pharyngeal wall are simultaneously suppu- 
rating, the mucous membranes of the opposing surfaces are 
brought so closely in contact with one another, by the swelling 
of the tissues, that adhesions form between them, and the en- 
tire free border of the velum and uvula becomes firmly united 
to the posterior wall of the pharynx by radiating white cica- 
tricial tissue. This may occur to such an extent that commu- 
nication between the pharyngo-oral and pharyngo-nasal cavity 
is totally blocked up, and the patient is compelled to breathe 
through the mouth alone. But if the patient loses the uvula 
before the velum becomes adherent, the latter will become fixed 
backward, and form a triangular fissure, whose apex is directed 
toward the hard palate, and base toward the posterior wall of 
the fauces — a deformity which does not interfere with the 
process of respiration in the least. 

The syphilitic affection of the posterior parts of the fauces, 
like that of the pharynx, as a rule, does not become apparent 
until the specific diathesis has existed for some time. Erythe- 
ma and papular eruptions attack these parts less frequently, 
and do not present any peculiar features. We have never 
been able to detect any mucous-membrane papules on the 
pharynx. Suppurating gummata are more frequently observed 
here. Gumma of the posterior wall of the fauces is usually 
situated along the lines corresponding to the transverse pro- 
cesses of the vertebrae. By the disorganization of the nodes, 
dirty, repulsive, deep ulcers originate ; they may extend to the 
periosteum of the vertebrae, and cause caries and necrosis of 
the latter, whereby even the cervical spinal marrow may be 
laid open. In some cases — though fortunately this is very rare 
— the ulcers will spread, especially in cachectic persons, upward 
into the posterior nares, downward into the pharynx, and even 
into the larynx. 

If caries and necrosis of the cervical vertebrae have devel- 
oped, healing of the ulcer is hardly to be expected ; but if the 
ulcers only affect the mucous membrane, they will heal, and ra- 
diating cicatrices will result. The cicatrix of the mucous mem- 



238 PATHOLOGY AND TREATMENT OF SYPHILIS. 

brane lias a glossy, dry appearance (xerosis), and the patients 
constantly complain of a feeling of dryness in the throat. 

Ulcers of the pharynx {pharyngitis syphilitica) originate 
either by the extension of the ulceration from the posterior wall 
of the fauces, or by the disorganization of a gumma that has 
developed at the entrance of the pharynx. So long as the 
pharyngeal node is small and unopened the patients experi- 
ence little more than dryness in the throat, but if it has broken 
open they will complain of burning and pricking pains, which 
become aggravated on swallowing. If the ulcer is confined to 
the pharynx, no alteration of the voice will result, but it is apt 
to extend downward into the larynx, and upward along the 
posterior wall of the fauces to the velum. For the purpose of 
discovering the site of the ulcer, it is necessary to depress the 
root of the tongue as much as possible ; sometimes we may 
succeed in feeling with the index-finger its upper indurated 
margins. If the pharyngeal ulcer is small and superficial, it 
will cicatrize without leaving any mark ; deep ulcers, on the 
other hand, always leave radiating cellulo-fibrous cicatrices, 
which may produce strictures of the pharynx. 

Syphilitic Disease of the Tongue. 

The tongue may become affected during the early period 
of syphilis, as well as during its latter phases. During the 
condylomatous stage, maculae and papules, but no diffused ca- 
tarrhal inflammation, originate upon the mucous membrane 
of this organ. During the gummatous stage, all the tissues 
entering into the structure of the tongue may be affected by 
the syphilitic process (glossitis syphilitica indurativa and gum- 
mosa). 

The macular form manifests itself by a more or less pro- 
nounced, sharply defined, erythematous, circular, superficial 
eruption, mostly situated on the upper surface of the tongue. 
The spots generally develop without causing any pain ; some- 
times, especially when they have begun to undergo their des- 
quamating metamorphosis, they occasion unpleasant sensations 
during chewing and speaking. 

The papular form develops on the upper surface as well 
as on the margins and tip of the tongue. As a rule, five or 



SYPHILIS. 239 

six papules, of the size of a lentil, originate, at the root of 
the tongue, but do not attract attention till their epithelial 
covering has become opaque, or the latter has already been 
cast off. They coalesce on the margins of the tongue and 
at the tip ; they only appear in the form of opacities of the 
epithelial layer (psoriasis linguae). 

In consequence of the mechanical action of solid and liquid 
food to which the tongue is constantly exposed, and the press- 
ure and irritation often caused by sharp and angular teeth, the 
primary type of the papules soon disappears, and they be- 
come converted into longitudinal or S-shaped, readily bleeding 
fissures, with a coating of grayish-white detritus, and mark- 
edly indurated borders, as a result of the inflammatory reac- 
tion. After these fissures heal, oblong cicatrices often remain. 

Sometimes there are found, on the borders of the tongue 
and on the mucous membrane of the lips of syphilitic patients 
who have recently been subjected to an insufficient mercurial 
treatment, a number of aggregated whitish papular opacities, 
varying in size from a millet- to a hemp-seed, which the French 
writers call mugnet, but, according to H. Zeissi's experience, 
are nothing else than papules that were aborted by the mercu- 
rial treatment. 

Mucous-membrane papules of the mouth and tongue are 
most frequently mistaken for aphthous affection and sprue ; 
further, for the morbid alterations which may originate from 
stomatitis mercurialis. 

The following symptoms may serve to distinguish aphthous 
affections from mucous-membrane papules of the mouth and 
tongue : Aphthae cause pain from their very beginning, even 
before the epithelial cells have become opaque. They present 
the appearance of small granules, are not bigger than a millet- 
seed, surrounded by a narrow zone, and on their apices a blackish 
dot is sometimes seen, due to a minute drop of blood; and 
before they become opaque, these granules often are converted 
into vesicles of the size of a pin's head. Mucous-membrane 
papules from the commencement display the features of flat 
pimples, are about the size of a lentil, have a dark-red color, 
are totally painless at this stage, and soon become covered with 
a pearly-white epithelial layer. However numerous aphthae 



240 PATHOLOGY AND TREATMENT OF SYPHILIS. 

may be, they do not become confluent, like syphilitic mucous- 
membrane papules. Aphthae sometimes give rise to small 
ulcers, like erosions, which heal from the circumference toward 
the center. Syphilitic erosions, especially those that have been 
preceded by confluent papules, heal from the center toward 
the circumference. Aphthee are seldom situated upon the 
tonsils and palate; syphilitic mucous-membrane papules are 
very often found in this locality. Aphthse of the mouth, as a 
rule, is a disease of childhood rather than of adult life, and 
the aphthous spots in the former are situated almost always 
at the line of junction between the hard and soft palate, while 
syj^hilitic mucous-membrane papules never occur at this spot. 

It will be quite easy to distinguish syphilitic papules from 
thrush, for the spores and fungi fibers (oidium albicans) may 
be readily seen with the microscope. 

The morbid alterations which result as the effects of mer- 
curial preparations are distinguished from specific papules by 
the following peculiarities : Mercurial sloughing sores occur 
almost exclusively on the borders of the tongue, on the mucous 
membrane of the lower lip and gums of the inferior maxilla. 
Syphilitic papules occur by preference on the upper surface of 
the tongue ; less frequently and less numerously on its borders. 
The parts of mucous membrane altered through mercurial 
salivation never display the pearly-white, glossy color of the 
opaline plaques, nor the grayish-white appearance of the dis- 
organized papules ; their color is dirty-greenish, and they are 
covered with a soft, pultaceous slough. The morbid altera- 
tions produced by mercurial ptyalism are due, in the further 
course of the process, to disorganization of the normal mucous 
membrane ; syphilitic mucous-membrane papules, on the con- 
trary, represent disorganized inflammatory foci, in which a 
certain amount of plasticity is often noticeable by the fact that 
some of the papillae found at these places proliferate, and this 
proliferating structure produces a hypertrophied epithelial en- 
velope. In many cases the peculiar disgusting odor of mercu- 
rial stomatitis will promptly aid the physician in forming a 
correct diagnosis. 

"We have had several opportunities of treating an affection 
of the mucous membrane of the tongue which might readily 



SYPHILIS. 241 

be mistaken for syphilitic plaques. This affection consists of a 
diffused thickening of the epithelial cells of the upper surface 
and borders of the tongue. The hypertrophied cells are cast 
off at some places, and then succeeded by new whitish cells 
that become thickened in their turn ; or abrasions, deprived of 
epithelial cells, and which are exceedingly painful, result there- 
from. The genesis of this lesion of the epithelial cells of the 
tongue, which is correctly designated as epithelial catarrh 
of the organ, is totally inexplicable. Sometimes it heals spon- 
taneously and very quickly ; sometimes, again, it speedily re- 
curs as intensely as, if not more so than, before, and generally 
lasts several months. It is readily distinguished by the size 
of the hypertrophied epithelial cells, by the intensity of the 
pain, by the absence of all phenomena pointing to syphilis, and 
by the inefficacy of anti-syphilitic treatment. 

Owing to the tendency to inflammations which syphilis pro- 
vokes, proliferations of the connective tissue in various organs 
ensue. These proliferations are either diffused and noted for 
the tendency to become indurated, or they are limited to a few 
circumscribed parts, and then form nodes which very often and 
very quickly degenerate, and thus in a short time, often in a few 
days, cause a considerable amount of destruction. If the affec- 
tion of the tongue has been preceded by a marked increase of 
the interstitial connective tissue, we call it glossitis syphilitica 
indurative^, while if nodes have formed it is known as glossitis 
gummatosa. Glossitis syphilitica indurativa may be either dif- 
fused or circumscribed, it may be limited to the mucosa, the 
muscular tissue or the interstitial connective tissue, or all of 
the tissues of the tongue may be simultaneously involved. In 
consequence of this condition the tongue often swells up so 
intensely that it is too big for the mouth. It is extremely red, 
occasionally markedly sensitive and painful. The swelling, 
hardness, and redness of course affect only the diseased part, 
which then projects above the level of the sound portion, 
and, owing to the disappearance of the papillae, in conse- 
quence of the inflammation, looks as if it were scraped off. 
The sound part of the tongue may remain perfectly normal. 
The epithelial cells of the diseased places gradually become 
opaque, finally acquire a pearly whiteness, and, owing to the 
16 



24:2 PATHOLOGY AND TREATMENT OF SYPHILIS. 

saliva floating upon them, become glossy as if varnished. The 
alternate red, normal, and diseased white spots give the tongue 
a tiger-like spotted appearance (Fournier). If the inflamma- 
tion is limited to a small superficial spot of the lingual mucous 
membrane, we call it glossitis syphilitica circumscripta super- 
perficialis. If the lingual muscular tissue is attacked by the 
circumscribed inflammation, it will feel to the touch like a 
hard, little lump, and the process will remind one of the dis- 
ease in other muscles affected by syphilis. We call this form 
glossitis muscularis syphilitica indurativa circumscripta ; if 
the entire or a greater part of the superficial surface of the 
tongue is affected, it is known as glossitis syphilitica indurativa 
diffusa superficialis y while if the inflammation has involved 
the greater part or the entire lingual parenchyma, it is termed 
glossitis indurativa diffusa profunda. This inflammation of 
the tongue may have a twofold termination. It may result 
either in a permanent hypertrophy of the tongue, or, in conse- 
quence of the shrinking of the neo-plastic growth, the organ 
may acquire a lobulated appearance. After the cessation of 
a circumscribed inflammation, a large or small node projecting 
above the surface of the tongue may remain, which is difficult 
to differentiate from an induration following an ordinary in- 
flammation. Syphilitic inflammation that affects the entire 
parenchyma of the tongue may be succeeded by a condition 
that has been called macroglossia syphilitica. The borders of 
the tongue bear the impression of the teeth ; if one of the latter 
is gone, a portion of the tongue may proliferate into the vacant 
space and fill it up entirely. "When the neoplastic connective 
tissue shrinks, shallow or deep grooves of the tongue will re- 
sult, depending upon circumscribed proliferation of the con- 
nective tissue. If the inflammation was diffused, the fissures 
will be so numerous as to give the tongue a ragged appearance. 
The furrows lying near the median line run parallel with it, 
while those on the borders are directed horizontally toward it. 
The entire diseased territory is nodular and uneven. In re- 
gard to the location of the affection, the upper surface of the 
tongue especially is affected, the lower being less frequently 
the site of the disease. 

The second form under which syphilitic proliferations of 



SYPHILIS. 243 

connective tissue may occur is, as we have already remarked 
above, gumma syphiliticum. 

This kind of tumor, if it originates in the tongue, may be 
situated either in the mucous membrane or the muscular struct- 
ure, or it may be so large as to involve the entire thickness 
of the organ. In regard to the gummata of the muscular 
tissue we believe that the tumor originally develops from the 
interstitial connective tissue, but after a while it encroaches 
upon the muscular tissue. In regard to the termination of 
the tumor, it may be made to disappear entirely, provided a 
judicious anti-syphilitic treatment is instituted early enough. 
The gumma disappears by resolution, often so completely that 
the texture of the tongue at the affected places atrophies to 
the thinness of a card. The majority of these neoplasms, 
however, if left untreated, will undergo disintegration. A 
caseous disorganization sets in at the center and spreads to- 
ward the circumference. Finally, an excavated ulcer with 
hypertrophied and sharply outlined borders originates and 
constantly extends into the adjacent healthy tissues. 

If these ulcers are subjected to an appropriate local and 
general treatment, the hypertrophied borders will, first of all, 
grow thinner, and then the solution of continuity will be filled 
up by whitish, radiating, cicatricial tissue. 

Gummata, originating in the mucous membrane of the 
tongue, will be most frequently met with at the apex of that 
organ, on its borders or in the space between the papillse val- 
latis. JSTaturally the height of a gumma of the mucous mem- 
brane can not be very great, for the reason that the lingual 
mucous membrane on the anterior part, being intimately united 
with the muscle of the tongue, is quite thin. But toward the 
root of the tongue we occasionally find larger nodes, because 
here the mucous membrane is less firmly united to the subja- 
cent muscular structure, and a comparatively large amount of 
submucous tissue is present. 

A syphilitic node of the tongue develops without causing 
any pain ; it is quite rare, and generally occurs singly. Some- 
times it is the only striking symptom which points to the pres- 
ence of the syphilitic diathesis that is undermining the entire 
system. 



244 PATHOLOGY AND TREATMENT OF SYPHILIS. 

A lingual gumma renders speaking difficult and prevents 
mastication. 

In patients suffering from inveterate syphilis we found re- 
peatedly the plica fimbriata on both sides of the freenum of the 
tongue infiltrated and hypertrophied to such a degree that it 
looked like a supernumerary tongue. 

There are probably no diseases that are so often mistaken 
for one another as carcinoma and gumma of the tongue. They 
differ, however, in the following particulars : Gumma never 
causes such intense pains as carcinoma. The disorganization 
of a lingual syphilitic node takes place from within outwardly ; 
the disorganization of a carcinomatous tumor goes on from the 
circumference toward the center. Further, as a rule, the sub- 
maxillary and sublingual glands swell up in carcinoma of the 
tongue to a size never met with in syphilitic adenitis. The 
most important differential symptom whereby the physician 
will be able to distinguish epithelioma of the tongue from 
specific morbid alterations, is the sebum-like plug, which in 
epithelioma may be squeezed out from the diseased part of the 
mucous membrane, a phenomenon that never occurs in the 
syphilitic affection. A microscopical examination of the dis- 
organized structure of carcinoma will reveal the well-known 
cancer-cells. If the physician does not find the differential 
symptoms enumerated here well marked, he may fall back 
upon the most reliable test, potassium iodide, which will cause 
the gumma to disappear in a few weeks, while in the carcinom- 
atous disease it will be totally inert. 

Finally, Hutchinson, in the " London Hospital Reports " for 
the year 1866, describes cases in which syphilitic nodes of the 
tongue became converted into carcinomatous- tumors* 

Syphilitic Disease of the (Esophagus. 

Diseases of the oesophagus in consequence of acquired 
syphilis are extremely rare. We have never had the oppor- 
tunity of seeing such a case, but a few undoubted instances 
of this disease may be found as curiosities in medical litera- 
ture. The affection of the oesophagus generally is caused by 
gummata, which, if they undergo disorganization and con- 
tracting cicatrices originate during the process of healing, re.r 



SYPHILIS. 245 

suit in the formation of strictures of the tube. The simul- 
taneous presence of some characteristic symptoms of syphilis 
in other parts of the body will materially simplify the diag- 
nosis. 

Syphilitic Disease of the Stomach and Intestines. 

Lancereaux, Wagner, and Klebs have furnished us with 
dissertations upon syphilitic diseases of the stomach. Although 
affections of the rectum in consequence of acquired syphilis 
are apt to occur frequently, so far we have had no opportunity 
of seeing a case of specific disease of the duodenum, jejunum, 
ileum, or of the large intestines,, Meschede, Oser, and Klebs 
have reported such cases. Affections of the small intestines 
in consequence of hereditary lues occur more frequently, and 
we will revert to the disease again when we come to speak of 
hereditary syphilis. As a result of acquired syphilis, the spe- 
cific primary lesion, as well as luetic papules and gummata, 
occur in the rectum. The syphilitic primary lesion is liable to 
produce strictures of the rectum. However, we can only form 
a correct diagnosis if these strictures have been made to disap- 
pear under anti-syphilitic treatment without the co-operation of 
dilating instruments, and the so-called secondary phenomena 
subsequently appear upon the skin or on the mucous mem- 
brane without any other primary specific lesion having been 
observed on the patient. However frequently we saw papules 
on and around the anus, yet rarely did we see them on the 
mucous membrane of the rectum. Papules around the anal 
opening and in the anus frequently become exceedingly large 
in consequence of the irritation to which they are constantly 
exposed. They often degenerate, and as a result of the secre- 
tion which they discharge condylomata (exuberating conical 
condylomata) originate upon them. Disorganized papules of 
the rectal mucous membrane generally generate only super- 
ficial ulcerations, and hence in our opinion they seldom give 
rise to strictures of the rectum, though Huron and Malassez 
maintained that they are the most frequent factors in producing 
them. 

The morbid alterations caused by gumma of the rectum 
are more severe than those produced by papules of that part. 



246 PATHOLOGY AND TREATMENT OF SYPHILIS. 

The affection occurs mostly as a gummatous infiltration of the 
submucous tissue, by which some of the infiltrated longitudinal 
folds swell up and project above the others. By degeneration 
of the infiltrated material, there originate either on the edges 
of the folds or in the grooves between them narrow, dirty-look- 
ing, oblong ulcers, which penetrate the entire thickness of the 
mucosa, so that their bases are formed either by the submu- 
cous connective tissue or by the muscular layer of the sphinc- 
ter. Cicatrization takes place either by a union of two or 
more adjacent folds, or, after a fold has been entirely destroyed 
by the ulcerative process that began on its margin, by granu- 
lations. In both cases the rectum often becomes so narrow 
that even an ordinary catheter can not pass through the con- 
stricted part. However, circumscribed gummata may also 
originate in the submucous tissues of the rectum, which may 
undergo degeneration, resulting in deep ulcers that penetrate 
the mucous membrane, and whose cicatrization is followed by 
grave strictures. 

The painless, rapid development of these tumors, their 
speedy disorganization, and the fact that the disease mostly at- 
tacks younger persons ; lastly, that they are preceded by other 
phenomena of syphilis — will aid the physician in forming a cor- 
rect diagnosis. 

In syphilis of the rectum, strictures do not form till the 
suppurating process has been cured, while in carcinoma the 
symptoms of stricture appear long before the cancerous degen- 
eration sets in ; and in addition the patients present the char- 
acteristic cachectic appearance. 

The prognosis is unfavorable. It will be necessary to prac- 
tice dilatation for a long time in order to relieve the patient of 
his malady. The dilatation of the gut must be carried out with 
the utmost care. We have seen severe peritonitis produced in 
cases where this procedure was performed in a rough manner. 

If only the upper layer of the sphincter is affected by the 
degeneration and sloughing of a gumma, and the deeper ones 
continue to perform their function, a spasmodic closure of the 
sphincter during defecation, attended by severe pain, will re- 
sult. But, if the muscular layers are destroyed at one or sev- 
eral places, a patulous state of the sphincter, involuntary evac- 



SYPHILIS. 247 

uation of fseces, and prolapse of one of the walls of the rectum, 
will take place. The ulcerations finally may be so extensive 
that the descending colon is perforated, grave hemorrhages 
ensue, and the patient dies from peritonitis. 

Syphilitic Affections of the Liver. 

Yirchow divides syphilitic diseases of the liver into peri- 
hepatitis, interstitial and gummatous hepatitis. All these 
three affections may exist simultaneously, and, according to Yir- 
chow, perihepatitis and interstitial hepatitis are always found 
together. Perihepatitis is sometimes seen in the form of 
finely granular, miliary dots, extending over large tracts, but 
most marked where the process has attained its greatest degree 
of intensity within the organ. Not only do hard, thick, hyper- 
trophies of the capsule form here, but almost always adhesions 
to adjacent organs, especially the diaphragm. These adhe- 
sions are remarkably thick and strong, so that long ligament- 
ous strings and bands extend from the liver to the diaphragm. 
These strings of cellular tissue, however, also send prolonga- 
tions into the parenchyma of the liver, which, like cicatri- 
cial substance, gradually contract, and cause shrinking of the 
superficial surface of this organ. The organ is transformed 
into a number of globular protuberances and globe-segments, 
i. e., it becomes multilobular. The lobulation of the liver, ac- 
cording to Kokitansky, is produced by the shrinking of the 
fibrous structure which has formed from a previous pylephle- 
bitis in the course of the portal vein. According to Wagner, 
the projections of the liver originate from the contractions of 
cicatricial tissue that remains after the gumma has undergone 
resolution. Schiippel agrees with Wagner, but adds that the 
syphilitic neoplastic growth, if it occurs in the form of large 
nodes, preferably follows the course of the portal vein, and 
embraces it on all sides. 

The new growth, the gumma, which is peculiar to syphilis, 
is mostly found wedged in between and near the hypertrophied 
cicatricial tissue just mentioned ; the former, however, also 
occurs in apparently normal hepatic parenchyma. Hepatic 
gummata frequently attain the size of a pea, or even that of 
a hazel-nut. On incising a liver that has undergone the de- 



248 PATHOLOGY AND TREATMENT OF SYPHILIS. 

generation above described, the gurnmata will be seen in the 
white cicatricial connective tissue, varying in form according 
to the stage of their development. Some are of soft, elastic 
texture, and for that reason spring up above the incisions, re- 
sembling very much, as L. Meyer, of Hamburg, correctly says, 
the glandular structure of the pancreas. They are yellowish, 
resemble tubercles, from which, according to Virchow, they 
are distinguished, in addition to their size, by their site within 
or near atrophied scars,* next by their dryness and uniformity, 
since hepatic tubercles, if somewhat large, always become soft. 
The number of gurnmata that may be present in the liver va- 
ries very much ; sometimes there are only two or three, some- 
times again eight or ten, and in still other cases an even larger 
number have been found. The majority of them are situated 
upon the surface of the liver, and in such places where trac- 
tion or some other mechanical irritation takes place ; for in- 
stance, at both sides of the ligamentum suspensorium. It is 
true that they are found in the deeper parts of the organ also, 
but then they are almost always connected with the superficial 
surface by narrow fibrous brands which hold them low down 
by the retraction the latter undergo (Klebs). 

The ramifications of the portal vein and of the hepatic and 
biliary ducts, however, usually do not remain unaffected. In 
consequence of the impeded circulation in the domain of the 
portal vein, ascites may originate, in the same manner as in 
interstitial inflammation, or in cirrhosis of the liver. It is not 
yet quite clear why icterus occurs in some cases and not in 
others. The substance of the liver remaining between the 
cicatrices and the nodes may be normal, or it may be in a con- 
dition of fatty degeneration (Frerichs) ; in other cases there is 
hypertrophy characterized by enlargement of the acini and 
liver-cells (Virchow) ; or, lastly, the nodes are imbedded in an 
amyloid liver. In addition, syphilis may produce that morbid 
alteration of the texture that has been denominated waxy liver 
(Wetzlar). 

In the simple perihepatitic form the liver is somewhat en- 
larged, but it shrinks when the inflammation attacks the inter- 
stitial tissue (syphilitic cirrhosis) ; if gurnmata are present, it is 
usually larger ; still, even in this case, it often becomes smaller, 



SYPHILIS. 249 

in consequence of atrophy of the normal parenchyma. The 
syphilitic liver is permanently and extraordinarily hypertro- 
phied only when it also undergoes lardaceous degeneration. 

Syphilitic disease of the liver is very often associated with 
hypertrophy of the spleen. Otherwise it gives rise to the same 
symptoms as a non-syphilitic cirrhosis, such as dyspeptic phe- 
nomena, constipation, hsematemesis, hsemorrhoids, epistaxis, 
anasmia, etc. 

The most important sign pointing to the presence of syphi- 
litic disease of the liver is undoubtedly the alteration of the 
organ itself; but despite a careful physical examination, and 
the indubitable anatomical signs furnished by the most .pro- 
nounced morbid process, we are not always able to avoid mak- 
ing mistakes in diagnosis. Perihepatitis and cirrhosis syphi- 
litica differ in no respects from other hepatic affections that 
result in either hypertrophy or atrophy of the organ. The 
presence of syphilitic cicatrices or nodes in the liver is the 
only reliable diagnostic sign ; still, even in this case, it is neces- 
sary first to exclude all affections that occasion similar morbid 
alterations, such as the granular liver, carcinoma of the liver, 
the shrinking of the liver following obliteration of some of the 
branches of the portal vessels, and obsolete echinococci cysts. 

In all cases the physician will find a detailed clinical history 
and thorough examination absolutely indispensable. Yet the 
statement of the patient should not be deemed sufficient. If 
there be the least suspicion that the case is one of syphilis 
of the liver, the organs in which the specific disease is apt to 
occur in various forms should be subjected to the most careful 
examination ; for there will almost always be found cicatrices in 
the pharynx, swelling of the lymphatic glands, exostoses, etc. — 
in short, symptoms that have been designated with the names 
of secondary or tertiary syphilis. In regard to the diagnosis of 
waxy liver, Wetzlar maintains that, in those cases in which the 
history points to syphilis, and the physical examination shows 
the presence of the morbid alterations peculiar to that disease, 
although no other striking symptoms are present, such as 
might be expected from the extent of the disease, one is justi- 
fied in assuming the lesion to be waxy liver, all the more so 
when it is associated with an enlarged spleen. It is not so 



250 PATHOLOGY AND TREATMENT OF SYPHILIS. 

easy to decide to which stage of the syphilitic infection the 
hepatic affection belongs. Oppolzer, like Dittrich and (rub- 
ier, has seen cases of hepatic syphilis which were associated 
with the so-called secondary form ; nevertheless, most instances 
belong to the later phase of the disease. 

The affection of the liver that has just been described is 
also a tolerably frequent phenomenon in hereditary syphilis. 

The prognosis is not absolutely unfavorable ; indeed, in- 
stances of hepatic syphilis are occasionally found at the autopsy 
of persons who died from some totally different disease, and 
the affection of the liver was not even suspected, no symptoms 
of it having been present during life. In general, the prog- 
nosis is more favorable while the liver is in the stage of hyper- 
trophy than when it has already commenced to atrophy. The 
concomitant affections of the syphilitic cachexia, dropsy, pro- 
tracted diarrhoea, disease of the kidneys (amyloid degeneration), 
secondary inflammation of the pleura and lungs, are significant 
of an evil termination. According to Wetzlar, the waxy liver 
is speedily cured by specific treatment. 

Syphilitic Affection of the Spleen. 

Weil, of Heidelberg, described an enlargement of the spleen 
that occurs in the earlier stages of the disease, which he claimed 
could be made to disappear by antispecific treatment. Many 
writers have described morbid alterations of the spleen found 
in syphilitic cadavers, such as hypertrophy, thickening of the 
capsule, cicatrices, etc. In our opinion, however, these can 
not be ascribed to syphilis with absolute certainty. Nothing 
but gummata are infallible productions of syphilitic origin. 
Nodes in the spleen have been described by Rokitansky, Vir- 
chow, Biermer, Wagner, Gold, and other reliable writers. 

Syphilitic Affection of the Pancreas and of the Salivary Glands. 

No other instances of syphilitic affections of these glandu- 
lar structures are known, with the exception of those reported 
by Lancereaux and Yerneuil. The former found, in one case, 
two gummata in the pancreas, in addition to some in the mus- 
cles. In another case he found the submaxillary gland on the 



SYPHILIS. 251 

left side markedly fissured and tabulated, very dense, yellow- 
ish, due to fatty degeneration ; in addition, cicatrices of ulcers 
on the posterior wall of the fauces, conjointly with pul- 
monary and hepatic syphilis, and a gummatous tumor in the 
pericardium. 

Syphilitic Affections of the Larynx and Trachea. 

By Professor Schrotter. 

"We are unable to give exact figures in reference to the 
frequency of laryngeal syphilis in cases of general syphilis. 
We can only avail ourselves of the figures showing how many 
patients among those who sought relief from throat troubles 
suffered from laryngeal syphilis. If we avail ourselves for 
that purpose of the number of cases that came under our ob- 
servation during eleven years (1871 to 1881 inclusive), it will 
be found that, among 21,044 cases of diseases of the throat, 
four and a half per cent were syphilitic, a number certainly 
less than has been supposed. 

However, it may be observed that, in very many cases of 
general syphilis, the specific affection of the larynx is totally 
overlooked, because it often runs its course with such slight 
symptoms that the patients do not find it necessary to seek re- 
lief. Hence reliable statistics could only be obtained by sub- 
jecting every patient in the syphilitic department of a hospital 
to a laryngoscopical examination. 

In regard to age % it is found that in men, those between 
twenty and thirty, in women, those between seventeen and 
thirty years, form the bulk of the patients. Children, accord- 
ing to our observations, seem to be even less affected than very 
old persons, among whom there was one man of seventy-four 
and one woman of seventy-two years. 

In regard to occupations, notwithstanding the great mass 
of material at our command, no definite facts could be gathered 
tending to show that it exercised any influence upon the spe- 
cific disease of the larynx. ISfor could it be proved that per- 
sons who work mostly out-of-doors, or those compelled to talk 
a great deal, were especially liable to this form of disease of 
the larynx. 



252 PATHOLOGY AND TREATMENT OF SYPHILIS. 

Acute and Chronic Catarrh. 

Levin, who has a large field of observation, recently made 
the assertion that the affection of the larynx, as a result of 
syphilis, never becomes catarrhal, always remaining erythema- 
tous in degree. We can not coincide with his view of the 
matter, for, not only are the various degrees of redness (hy- 
peremia) to be seen on the affected mucous membrane, but 
even such symptoms as are produced by affections of other 
mucous membranes collectively, and have been called catarrh, 
are present here. 

There is found a slight or more marked swelling, not only 
of the affected structures, but, as Levin himself has admitted, 
of the submucous tissue also, and an alteration of the secretion ; 
in some cases it is diminished, in others again considerably in- 
creased. Furthermore, the epithelial cells, especially on the 
vocal cords, are cast off in some places, in others markedly 
thickened — conditions that are admitted by all authorities to 
constitute catarrhal disease. 

The duration of the affection, too, is very often greater than 
in erythema. Lastly, we have the fact, and certainly it is not an 
unimportant one, that such a pathological condition heals very 
rapidly under an anti-syphilitic treatment, while it most obsti- 
nately resists a treatment with anti-catarrhal remedies, such as 
astringents, etc. This certainly proves that it was not a mere 
accidental affection, such as is caused by a cold from which the 
syphilitic patient was suffering. 

The catarrhal affection very often accompanies a catarrh of 
the fauces. The phenomena are not more serious, save in re- 
mote complications, and generally present the appearances of 
subacute and chronic inflammation. 

There are no differential data for distinguishing it from 
idiopathic catarrh, or from that occurring in consequence of 
other affections. At one time we thought that a greater de- 
gree of exfoliation of the epithelial cells, especially on the bor- 
ders of the vocal cords, occurred in syphilitic catarrh, than in 
the non-specific affection. Subsequent experience, however, 
has taught us that this view was incorrect ; neither does the 
quality of the secretion supply any proof of the character of 



SYPHILIS. 253 

the lesion. The same kind of tenacious mucus occurs on the 
margins of the vocal cords — it agglutinates them ; and, when 
it becomes dry, forms crusts as in the idiopathic form. Nor 
would it be correct to state that the duration and the obstinacy 
of the disease furnish any indications regarding its syphilitic 
character. 

Hence the diagnosis can only be confirmed by the simul- 
taneous presence of other syphilitic evidences, which are often 
plainly manifest by the swollen cervical glands ; yet even this 
does not establish the diagnosis beyond all cavil, for it is quite 
possible that the patient has suffered from laryngeal catarrh 
before he. acquired syphilis, or that the affection was produced 
by some other causal condition. 

Although it must be conceded that this form of syphilitic 
infection, like the more intense manifestations of the spe- 
cific disease, may be cured by a general anti-luetic treatment, 
still it can not be denied that local treatment is of the greatest 
benefit. We do not mean a mere symptomatic treatment, 
such as, for instance, the inhalation of narcotic remedies for 
the relief of the cough and the tickling and scratching sensa- 
tion in the throat, but the local use of anti-syphilitic agents, 
such as inhalations of iodide of potassium, or a weak solu- 
tion of the bichloride of mercury, or penciling with iodo- 
glycerine, etc. 

If we do not speak of oedema of the larynx here, it is because 
we do not believe that it ever develops from a simple catarrh, 
but is always a collateral manifestation of disease of the deeper 
tissues, infiltration of the submucous structures, or still more 
frequently of the perichondrium. 

Papules. 

Papules are a tolerably rare form of disease in the larynx ; 
at any rate, they occur less frequently even than is supposed. 
Now and then they are found on the margin of the epi- 
glottis, over Santorini's cartilage, on the posterior surface of 
the arytenoid cartilages, and most frequently on the aryteno- 
epiglottic folds, in the form of oblong or rounded projections 
or swellings, varying in size from that of a lentil to that of a 
pea, and having a bright-red color. Gradually they grow here 



254: PATHOLOGY AND TREATMENT OF SYPHILIS. 

above the level of the tissues ; sometimes they are distinctly 
outlined ; sometimes, again, their borders are indistinct. Their 
upper surface, as a rule, appears granular, because the epithe- 
lial cells soon disappear ; some of them, however, are covered 
with a thick, whitish matter. If the epithelial coating is en- 
tirely gone, a few minute, red points are seen upon the yel- 
lowish purulent base of the papule. These forms may also 
occur on the anterior surface of the posterior laryngeal wall ; 
still, as it is impossible to obtain a satisfactory view of this 
region, nothing definite can be said upon that point ; for 
hypertrophy or exfoliation of some layers of the epithelial 
cells occurs so frequently as a consequence of chronic catarrh 
alone, that one must be very careful in judging pathological 
alterations occurring on these places. No post-mortem ex- 
amination of this lesion has ever been made. 

This form of disease, at any rate, occurs very rarely on the 
true and false vocal cords, and it will scarcely be possible to 
differentiate it definitely from other kinds of syphilitic infil- 
trations, which, when they undergo degeneration, go on to 
ulceration. 

Infiltrations, Gummata. 

Under this head, not only the circumscribed tumors, but 
infiltrations, such as often attack all the tissues of the larynx 
in a diffused manner, occurring in consequence of syphilis, 
belong. They occur more frequently than the former variety, 
and since they often terminate in grave, morbid alterations, 
are of much greater prognostic importance. 

They may occur on the epiglottis, partly in the form of 
single or multiple aggregated nodules of various sizes, partly as 
uniform hypertrophy of either its laryngeal or lingual surfaces, 
or both. In the severe forms of the disease, the graceful 
form of the epiglottis is lost, owing to the thickening of its 
substance, and in the highest grade the hypertrophy may be 
so great that both lateral borders touch each other, and then it 
becomes totally impossible to obtain a view of the laryngeal 
cavity. 

The same is true of the infiltrations in the aryteno-epiglot- 
tic folds. Here thick callosities also form. If the latter de- 
velop on the arytenoid cartilages also, the entire space between 



SYPHILIS. 255 

them will be filled up. If the gummata are located about the 
joints of the arytenoid cartilages, the movements of the latter 
will be markedly hindered. 

These hypertrophies are generally very dense, and the probe 
makes little impression npon them. 

They occur in various forms on the true vocal cords. Now, 
one or both vocal cords are swollen to such a degree that the 
patient is in danger of dying from asphyxia ; then, again, 
there is only a slight circumscribed swelling, which generally 
runs along the length of a cord, and is either pale or livid. 
Lastly, that form of tumor is of especial interest which has its 
starting-point from the lower surface of the vocal cords. As is 
well known, the border of the vocal cord, under normal circum- 
stances, constitutes a cavity facing downward and inward. In 
the infiltrations under consideration, so great a convexity pro- 
jecting into the larynx may originate in place of the concavity 
that the tumors thus formed in the median line touch one an- 
other, especially anteriorly, and thus only a small space re- 
mains posteriorly for the passage of air. This is a very fre- 
quent form of laryngeal stenosis. Now and then a distinct 
boundary-line originates also between such an hypertrophy and 
the edge of the true vocal cord, the infiltration being less marked 
on the connective-tissue lines running between the elastic 
fibrous bands. This often produces a picture, as if the vocal 
cord were split lengthwise ; and as this condition may occur 
physiologically (by the origin of the elastic fibrous band from 
the processus vocalis), and also from the ulcerations that creep 
along the whole length of the vocal cord, it is necessary to pay 
particular attention to it. 

If these infiltrations involve the false vocal cords, the con- 
dition soon manifests itself by the occlusion of the sinus Mor- 
gagni, and more or less covering up of the true vocal cords, 
the latter becoming more curved upwardly. This is usually 
attended by a marked increase of the redness, while on the 
true vocal cords the redness does not become so intense till 
later in the course of the disease, when purulent destruction 
occurs. 

The nodular form occurs on the lingual as well as on the 
laryngeal surface of the epiglottis — on the latter most fre- 



256 PATHOLOGY AND TREATMENT OF SYPHILIS. 

quently, perhaps on its petiolar part, on the ary-epiglottic 
folds, on the head and posterior surface of the arytenoid car- 
tilage, on the central part of the false vocal cords, on the lower 
surfaces of the true vocal cords, and, lastly, in the trachea too. 
The upper surface of the nodes, so long as they do not ulcer- 
ate, are perfectly smooth ; at first they are quite dark, but later 
become bright red. 

All these forms of nodular growths may be so completely 
absorbed that not even the place where they were situated can 
be found, or a less or greater degree of degeneration often takes 
place very rapidly, resulting in a syphilitic ulcer. It is a 
much rarer occurrence for such a swelling to terminate in per- 
manent hypertrophy by an abundant proliferation of connect- 
ive tissue. 

The fatty or lardaceous degeneration of the laryngeal mus- 
cular apparatus may be considered as still another termination 
of the syphilitic inflammation. 

It is evident that, under all these circumstances, a number 
of factors may concur that will change the voice from a slight 
hoarseness to total aphonia. 

Ulceus. 

These often develop with surprising rapidity. On the 
places where yesterday a marked redness still prevailed, to-day 
an ulcer with partly smooth and partly ragged edges is found. 
It is sharply defined, and its base may be red and transparent, 
or covered with yellowish matter. It is generally also sur- 
rounded by a red border. 

In the progress of the disease the ulcer may become of im- 
mense size. It may not only extend from the free margin of 
the epiglottis to both its upper and lower surfaces, but even to 
the cartilage. After the complete termination of the ulcer, 
which is usually asymmetrical, the cartilage is entirely exposed, 
or projects, at both ends of the ulcer, in the form of a sharp 
prong. If the ulcer extends to the ary-epiglottic folds, or if it 
originated upon the latter, or upon the arytenoid cartilage, the 
rigidity of the affected structures will frequently attract at- 
tention. 

Here, as in ulcers upon the false vocal cords, the borders 



SYPHILIS. 257 

of the ulcer are not infrequently thickened like a rampart. 
Such ulcers are very often found upon the anterior surface of 
the posterior wall of the larynx, and these are the ones that 
so often deceive the physician. As has been intimated, it 
is not even possible to get a good view of this part of the 
larynx, and when an ulcer occurs here little more than its up- 
per border will be seen. If it is at all fissured, or undermined, 
there originate, as viewed from above, indentations, which, to 
those unfamiliar with the true nature of the lesion, will appear 
to be excrescences, vegetations, condylomata, polypi, etc. As 
a protection against committing such an error, we will men- 
tion the facts that neoplastic growths are exceedingly rare at 
this place ; that the fine indented border of the projection, 
which is occasionally well defined, is readily recognized as a 
portion of the ulcer ; and, lastly, that the ulcer extends from 
the posterior laryngeal wall to the lateral parts of the vocal 
cords. These data, no doubt, will put an end to all danger of 
error. 

Ulcers on the false and true vocal cords, especially on the 
latter, spread in the direction of their long axis, destroying the 
borders and even a considerable portion of the cords. Often 
they extend so deep that the processus vocalis is exposed. 

The ulcer may extend downward into the larynx, trachea, 
and even into the bronchi. Not infrequently extensive ulcers 
occur, particularly at the bifurcation of the trachea. They 
often penetrate deep enough to perforate the trachea and attack 
the adjacent organs. 

The surface of the ulcer is usually covered with tenacious 
purulent matter. 

The question occurs very often, How can syphilitic ulcers 
be distinguished from other forms of ulcer, especially scrofu- 
lous, tuberculous, typhous, lupous, or carcinomatous ulcers ? 
The question is easily answered : The character of the ulcer, as 
a rule, can only be definitely settled by the clinical demonstra- 
tion of syphilis, or by the exclusion of other primary diseases. 
When this can not be done, the diagnosis will remain un- 
certain. 

This will become perfectly clear when we review the indi- 
vidual symptoms. 
17 



258 PATHOLOGY AND TREATMENT OF SYPHILIS. 

The site of the ulcer is no guide in forming a differential 
diagnosis. All kinds of ulcers occur on those parts of the 
larynx that are rich in glands ; thus, syphilitic, like tubercular 
ulcers, are met with on the anterior surface of the posterior 
wall of the larynx, on the petiolar part of the epiglottis, on the 
borders of the false vocal cords, and, lastly, on any other part 
of the larynx. Notwithstanding our very extensive experience 
we are unable to indicate any site of predilection of syphilitic 
ulcers in the larynx. 

It is true that the sharp border and the arched indentations 
of the ulcer speak with greater certainty for syphilis than for 
tuberculosis ; but, then, such conditions sometimes occur, not 
only in tuberculosis, but even in sloughing carcinoma, in which 
disease they are sometimes very pronounced. 

Tuberculous ulcers are often so covered with tenacious pu- 
rulent matter, and so enveloped in it, that their base can not 
be seen. After the secretion has been removed, by the ex- 
pulsive efforts of coughing or with a brush, the base will be 
found tolerably clean, pale, and slightly granulating. In a 
syphilitic ulcer, the discharge is less profuse, but, nevertheless, 
it is so intimately united with the base of the ulcer that it is 
almost impossible to brush it away. 

The condition of the tissues around the ulcer is a very im- 
portant symptom. In syphilitic ulcerations the surrounding 
tissues are mostly bright red, while in tuberculous ulcers not 
only the parts near them, but the entire laryngeal mucous 
membrane, is pale, often to a remarkable degree. Still, even 
this sign is not absolutely reliable ; for tuberculous ulcers may, 
on the one hand, be surrounded by reddened tissues, and, on the 
other, all mucous membranes in protracted syphilis may have 
an extremely ansemic appearance. 

So far we have only seen one phenomenon, which was fre- 
quently present in the vicinity of tuberculous ulcers, but never 
in consequence of syphilis — namely, a number of yellowish dots, 
varying in size from that of a pin's head to that of a millet-seed, 
which represent so many minute infiltrated glands. At first, 
they are somewhat scattered, but subsequently become more 
aggregated. After they undergo degeneration, in some cases, 
ulcers are seen to form, which grow larger and larger by the 



SYPHILIS. 259 

coalescence of some of the foci. "We have paid particular at- 
tention to this condition for a great many years past, and 
always found it to be a reliable diagnostic feature. These yel- 
lowish dots should not be confounded with the yellowish gran- 
ules that are sometimes found in the vicinity of a carcinoma ; 
in the latter case, they are larger, and distinctly range above 
the level of the normal mucous membrane. 

The condition of the adjoining nasal, pharyngeal, and oral 
mucous membrane may be regarded as a reliable guide. It is 
true that, in all probability, when the ulcer is extremely large, 
extending from the soft palate, root of the tongue, and the 
faucial mucous membrane, to the larynx, one will be apt to 
think of syphilis and not of tuberculosis : it might be per- 
fectly safe to do so if a scar is found at the same time on one 
of the places mentioned. Yet, aside from the fact that tuber- 
culous persons may also have syphilitic ulcers on the mucous 
membrane, and that in tuberculosis extensive ulcers, reaching 
from the root of the tongue to the soft palate and the gums, 
also occur, another difficulty becomes superadded, under these 
circumstances, namely, the differentiation between syphilitic 
and carcinomatous ulcers. 

We can recall more than one instance in which, after care- 
fully examining the entire body, we were unable to make a 
differential diagnosis between syphilis and carcinoma. After 
succeeding, in some instances, in bringing about a cure of the 
ulcers under anti-syphilitic treatment, we deemed ourselves 
justified in concluding the disease to have been syphilis. But 
when, after a short time, the ulcers broke out again, we found 
ourselves in the same doubtful position as before, and this was 
not cleared up till the fatal end. 

Swelling of the lymphatic glands in the submaxillary re- 
gion, and lower down in the neck, furnishes no differential 
diagnostic signs ; in a milder form, it occurs in tuberculosis ; in 
a severer form, in cancer as well as in syphilis. 

Lastly, in regard to typhoid ulcers, it will not be difficult 
to distinguish them from syphilitic ulcers when the whole mor- 
bid picture is reviewed, and ulcers as a result of lupus are 
found only when this affection occurs on other places. 

Hence, from all that has been said above concerning the 



260 PATHOLOGY AND TREATMENT OF SYPHILIS. 

differential diagnosis of laryngeal ulcers, it will be apparent 
that in all doubtful cases it will be necessary to carefully ex- 
amine the whole body, and minutely investigate all the circum- 
stances of the case. The symptoms of an ulcer of the larynx 
vary according to its site. 

An ulcer in the larynx alone, as a rule, causes no difficulties 
in swallowing. This is especially true in contradistinction to 
the wide-spread erroneous views concerning ulcers on the epi- 
glottis. Precisely as in tuberculosis difficulties in deglutition 
are only present when the ulcer spreads from the lateral wall 
of the larynx upward to the pharynx ; but especially is this the 
case when ulcers spread from the anterior to the posterior wall 
of the larynx. In the last two instances the pains which often 
radiate to the ear may be so intense that the patients decline 
to partake of any nutriment. Still, as a rule, the difficulties in 
deglutition are greater in tuberculous than in syphilitic pa- 
tients. Hoarseness is present when the vocal cords are directly 
affected or when they are less movable, or when the patient on 
account of pain avoids bringing into tension the necessary ap- 
paratus for the production of phonation. 

Haemorrhages in consequence of syphilitic ulceration of the 
larynx are always slight ; generally there are only a few dots, 
or, at the most, streaks of blood in the muco-purulent expecto- 
ration. We at least have never seen any bleeding worth mention- 
ing in syphilitic ulcers of the larynx, though we have witnessed 
some profuse, even fatal, haemorrhages in tuberculous ulcers of 
the fauces. 

The secondary symptoms in the larynx appear at the same 
time after the primary infection^ as on the other parts of the 
body. Sometimes the phenomena in the larynx occur for the first, 
time so late, so many years after infection, that it is difficult to 
trace any connection between them. It is necessary to remind 
the reader here of the question that has recently been discussed 
so much of the occasional late occurrence of hereditary syphilis. 

Although there is no doubt whatever that the general treat- 
ment, whether it consists of the inunction of mercury or the 
internal administration of iodide of potassium, corrosive sub- 
limate, Zittman's decoction, etc., is the most important, still it 
is not well to discard the local treatment entirely. Just as. 



SYPHILIS. 261 

little as we are satisfied to treat extensive specific sores on the 
skin with Zittman's decoction alone, but employ, in addition, 
lotions, plasters, and ointments in the most active manner, so 
little should we be content to await the effects of internal treat- 
ment in syphilitic laryngeal ulcers, for instance, on the vocal 
cords, without resorting to the use of local remedies before an 
irremediable loss of substance or erosion of the cartilages has 
taken place. 

The form of local treatment necessary in any given case 
will depend upon special circumstances ; but it will always be 
more advantageous to treat the affected places, if possible, by 
direct applications ; we mean thereby that more good will be 
accomplished by penciling the ulcers in the larynx with a solu- 
tion of nitrate of silver, iodo-giycerine, tincture of iodine, etc., 
than by inhalations. Of the latter, those consisting of iodide 
of potassium or iodide of sodium are to be preferred, while 
corrosive sublimate always gives rise to unpleasant secondary 
effects. Insufflations of finely powdered iodoform upon the 
ulcer have proved to be of great benefit. 

In ulcers of the trachea local treatment is not only useful, 
but often absolutely necessary, especially in those cases in 
which there is a marked accumulation of mucus or crusts that 
adhere tenaciously. 

Perichondritis. 

This is one of the most frequent forms of disease in syphi- 
lis ; and syphilis, again, is one of the most frequent causes of 
perichondritis laryngea. It occurs on all the cartilages of the 
larynx, and may start from the perichondrium itself as well as 
from ulcers of the mucous membrane that spread to the carti- 
lage. The lesion may terminate in all those morbid alterations 
that follow perichondritis in general, namely, abscesses, spread- 
ing of ulcers, grave destruction of carious cartilages which 
have become ossified, exposure of the cartilage in a suppurating 
cavity, and formation of cicatrices, with consecutive disfigure- 
ment of the shape of the larynx. 

Cicatrices. 
Syphilis is the most frequent cause of scars in the larynx. 
It is evident, from what has been said upon the subject of ul- 



262 PATHOLOGY AND TREATMENT OF SYPHILIS. 

cers, that thej may occur on any part of the larynx. In the 
slightest grades they require the closest inspection to see them ; 
in other cases, again, they are extensive and characteristic, be- 
ing met with in connection with ulcers on the hard palate, that 
has already been partly destroyed, on the root of the tongue, 
or lateral and posterior walls of the fauces. 

The disfigurement of the remains of the epiglottis may 
be very extensive ; we know, however, that deglutition even 
in cases of complete loss of the epiglottis may be accomplished 
without any difficulty. In scars of the posterior laryngeal wall 
and the vocal cords the glottis not infrequently is distorted. 
Those forms in which bridge-like bands originate on the ary- 
epiglottic folds, and especially on the false vocal cords, are very 
remarkable. Further, those scars that are on a level with and 
below the vocal cords, and which either bring about adhesions 
between them or membranous contractions of the glottis, de- 
serve special mention. These contractions generally occur at 
its anterior angle ; sometimes, however, they line the larynx in 
an annular form. 

There occurs very often from the contractions of the cica- 
tricial tissue, and the constriction of the blood-vessels resulting 
from it, disturbances of the circulation, followed by marked 
bulbous and oedematous thickening of some parts ; even new 
ulcers form again as the result of this pathological condition. 

Cicatrices on the posterior laryngeal wall surrounding the 
crico-arytenoidal joint will render it immovable. 

Scars often have a characteristic appearance. Still, a thor- 
ough examination of the clinical history of the case is indis- 
pensable, for other processes, especially eschars produced by 
solutions of caustic potash, may give rise to similar cicatrices. 

A scar very much like that described above occurs also in 
the trachea. Cicatricial bands that transverse its lumen in the 
form of a network are of great importance, for a slight accu- 
mulation of the secretion at this point may occasion the most 
dangerous attacks of suffocation if some of the meshes of the 
network become plugged up, and thus reduce the caliber of 
the trachea. 

Cicatricial contractions of the larynx may require various 
degrees of surgical interference. They may be so severe as to 



SYPHILIS. 263 

call for laryngotomy. If membranes have formed between 
the vocal cords and adhesions between the latter, their division 
with the knife will accomplish excellent results. These bloody 
operations must be supplemented by the use of laryngeal bou- 
gies of gradually increasing thicknesses, according to Schrotter's 
method. If the false membranes or scars are < not very thick, 
dilatation by means of bougies alone will in many cases an- 
swer completely. 

Constrictions of the trachea are to be treated in a similar 
manner. 

Kew Growths. 

Gummata having been already described, those growths 
which occur singly or in groups, and resemble pointed con- 
dylomata, remain to be spoken of here. They are met with 
mainly on the soft palate, upon the arytenoid cartilage and 
epiglottic folds, not so often on the anterior surface of the pos- 
terior laryngeal wall and on the vocal cords. Sometimes they 
form such high cockscomb-like excrescences that the probe 
sinks in between them to a depth of several millimetres. Paint- 
ing them with tincture of iodine will cause them quickly to 
disappear. 

These new growths, according to published reports, have 
also been found in the trachea. 

In conclusion, it is necessary to allude to those forms of 
disease which, although produced by syphilis, are not located 
in the larynx, and only manifest their influence upon this organ. 
Syphilitic diseased glands which temporarily or permanently 
interrupt the functions of the superior laryngeal nerve, or still 
more frequently the inferior laryngeal nerve, cause, by the re- 
sulting paralysis of the muscles of the larynx, not only hoarse- 
ness and aphonia, but even dangerous symptoms of suffocation. 
In these cases, the nature of the primary affection often re- 
mains an unsolved problem in physical diagnosis. 

Syphilitic Affections of the Bronchi and Lungs. 

From the character of the morbid lesions found after death, 
Yirchow came to the conclusion that syphilitic ulceration, 
with consequent cicatrization and stenosis, may occur in the 
bronchi, as it does in the larynx and trachea. Syphilitic bron- 



264 PATHOLOGY AND TREATMENT OF SYPHILIS. 

chitis may merge into chronic pneumonia, and the latter termi- 
nate in hyperplastic induration of the pulmonary structures. 
This form of interstitial pneumonia of specific origin is said 
to occur idiopathically also, and lead to the formation of callous 
nodules, of strong cicatricial bands running through the pul- 
monary tissues, and of cicatricial retractions of the pulmonary 
surfaces. Gummosities in the lungs undoubtedly occur in he- 
reditary syphilis ; in the acquired form they have been fre- 
quently met with and described. Nevertheless, their presence 
is not easily demonstrable, either clinically or pathologically. 
We must be able beyond a doubt to exclude the presence of 
tuberculosis, and for that purpose take into consideration the 
site of the morbid deposits. Gummata occur all over the 
lungs, while tuberculosis, in the vast majority of cases, is found 
at the apices. Finally, the antecedents and concomitants, the 
course of the disease, and the effects of anti-specific treatment, 
are very useful data in diagnosis. On the pleura, too, syphi- 
litic cicatrices, with prolongations extending into the pulmonary 
tissues, are said to occur. 

[Pulmonary syphilis is properly regarded as a late mani- 
festation of the disease. It occurs mainly in two forms, dif- 
fused and circumscribed. The diffused deposits are found 
along the course of bronchi and their ramifications, resulting 
in peribronchial infiltrations, whose retraction subsequently 
occludes the lumen of the bronchial tubes, producing collapse 
of that portion of the lung. If the infiltration extends to the 
surface of the lung, it will become apparent even before the 
pleura is removed. The circumscribed form occurs as gumma 
nodes, varying in size from that of a small kernel up to that of a 
walnut, and even larger, which are found imbedded in the pul- 
monary tissue. These gummata may undergo absorption, fatty 
degeneration, cheesy transformation, or softening and suppu- 
ration, but, in any event, callous cicatrices of dense connective 
tissue always remain. The diffused and circumscribed forms 
are pathologically alike, and differ only as regards their location. 

This lesion, as already observed, presents no pathogno- 
monic symptoms. But if dullness, on percussion, is found 
over a circumscribed space, and dyspnoea supervenes rapidly, 
in a well-developed, robust person, unattended by hectic fever, 



SYPHILIS. 265 

and some of the late evidences of specific disease are present, 
the disease may be considered pulmonary syphilis. The treat- 
ment with the iodides, and the absence of tubercle bacilli from 
the sputa, will, perhaps, form the most reliable evidences of 
the nature of the disease.] 

Affections of the Kidney, Suprarenal Capsule, and the Bladder. 

In addition to other diseases of the kidney found in syphi- 
litic patients, which, however, can in no way be distinguished 
from the pathological lesions found in non-specific Bright's 
disease, gummata and chronic interstitial, syphilitic, inflamma- 
tory circumscribed deposits have also been described by medi- 
cal writers. A few instances of similar affections of the supra- 
renal capsule are also recorded. 

In a few rare cases, syphilitic ulcerations and subsequent 
cicatrization occurred in the bladder, these processes being usu- 
ally accompanied by similar lesions in the urethra (Proksch). 

Syphilitic Affections of the Testicle and Spermatic Cord. 

The term syphilitic disease of the testis (orchitis, albuginitis, 
or sarcocele syphilitica) is applied to an inflammatory affection 
starting from the albuginea of the organ. In consequence of 
this, the albuginea and the cellular prolongations that extend 
from it into the substance of the testis, dividing it into small 
lobes, may become markedly thickened by proliferation of the 
connective tissue. In addition to this, however, there are some- 
times found, under the thickened envelope of the specifically 
diseased testicle, distinctly outlined nodules, as big as millet- 
seeds, containing a firm, yellowish nucleus. These have been 
regarded by Virchow and others as gummata. Hence, a sim- 
ple orchitis syphilitica and an orchitis gummosa may be dis- 
tinguished. But whether connective tissue alone has formed, 
or gummata have developed, can not be positively ascertained 
during the life of the patient. 

A commencing syphilitic disease of the testicle generally 
runs a totally painless course, and, for that reason, hardly 
ever attracts the attention of the patient. In exceptional in- 
stances, it manifests itself by slight pains, which run along the 
spermatic cord, radiating toward the corresponding inguinal 



266 PATHOLOGY AND TREATMENT OF SYPHILIS. 

region, but which are not aggravated by pressure upon the 
cord, a condition which Dupuytren considered as characteristic 
of syphilitic disease of the testicle. If the testis is carefully ex- 
amined at the beginning of the disease, one or more scattered, 
nodular, hard places, about the size of a hazel-nut, are found 
on its surface. 

By the gradual enlargement in circumference of the origi- 
nally indurated places, or by the gradual coalescence of the 
scattered inflammatory foci, the testis uniformly swells up, 
becomes as hard as cartilage, and twofold or even threefold its 
normal size. It thereby loses its oval shape, and becomes pyri- 
form, with its base directed downward and its apex drawn up 
toward the groin. The swollen testis is less sensitive to press- 
ure than a normal one. The epididymis, and the correspond- 
ing vas deferens, as a rule, remain unaltered. In exceptional 
cases, however, the epididymis becomes involved in the pyri- 
form swelling and the vas deferens is hypertrophied to two- 
fold and even fourfold its normal thickness. 

In some cases, a serous effusion takes place into the cavity 
of the tunica vaginalis propria. This hydrocele, which has 
been described as orchitis serosa, or vaginalis, and by Virchow 
termed periorchitis syphilitica, does not seem to us to stand 
always in causal relation to syphilis, but very often depends 
upon a transudation resulting from a simple passive stasis of 
the blood. 

Like its development, the entire course of the disease 
of the testis is slow and chronic. Its duration is uncertain ; 
sometimes it is prolonged for two or three years. During this 
period, however, the testis may spontaneously become smaller 
and larger again. So long as the swelled testicle is of moder- 
ate size, the scrotal integument suffers no morbid alteration ; 
but, when it has attained marked dimensions, or a considerable 
amount of serum at the same time is effused into the cavity 
of the tunica vaginalis, the wrinkles of the affected half of the 
scrotum gradually become effaced, and the skin of the scrotum 
erythematous. 

Syphilitic inflammation of the testis generally terminates by 
absorption of the inflammatory products. Sometimes, however, 
the resolution oversteps the limits of a normal condition ; the 



SYPHILIS, 267 

testis becomes smaller than it was before, and, finally, is atro- 
phied so much that it is reduced to a mere rudimentary condition, 
not bigger than a bean or pea. Further, there are cases in which 
the affected testis is converted into a mass as hard as cartilage 
or bone. A syphilitic testis seldom undergoes suppuration. 

As a result of syphilitic disease of the testicle, the secretion 
of semen is greatly diminished or totally arrested. If both 
testes are rendered functionally inefficient by specific disease 
of a high degree, a diminution of erections, loss of sexual ap- 
petite, and, finally, with increasing atrophy of the glands, 
complete impotence will result. Ricord states that the semen 
secreted by such testes is diminished in quantity and changed in 
quality ; that it contains no spermatozoa, and is simply a thin, 
transparent fluid. In the testicles of robust persons, who bore 
indications of having had syphilis which, however, had been 
completely cured, Levin found the spermatozoa were often ab- 
sent (in fifty per cent). These statements agree entirely with 
the observations made by H. Zeissl. He knew many men 
who had suffered from syphilis, and, notwithstanding that they 
possessed strong constitutions, begat no children, though their 
wives were perfectly healthy. 

At any rate, it is probable that the origin of syphilitic dis- 
ease of the testes may be fostered not only by certain local influ- 
ences, such as a fall, a blow on the testicle, or excesses in vene- 
ry, but that even remote causes, such as epididymitis blennor- 
rhoica, tuberculosis of the epididymis, or carcinoma of the 
testicle, may serve to engender a specific orchitis. But we 
must confess that, although very many of our syphilitic pa- 
tients suffered from gonorrhoea, yet no sarcocele was produced. 

In all cases that came under our treatment the affection of 
the testicles was the result of acquired syphilis. As a general 
thing, only one testis was diseased — now the right, and then 
again the left. In a few rare instances the second testis was 
attacked some time after the first. Orchitis syphilitica occurred 
most frequently in persons who were suffering from syphilitic 
ecthyma or specific nodes of the skin or mucous membrane. 

The affections of the testes, which may be mistaken for 
syphilitic inflammatory orchitis, are tuberculosis, carcinoma, 
and gonorrhoea! epididymitis. 



268 PATHOLOGY AND TREATMENT OF SYPHILIS. 

Tuberculosis of the testes, as is well known, always begins 
in the epididymis, and is either limited to this part, or subse- 
quently extends to the entire organ. The specific affection, 
however, attacks the testis first, the epididymis generally remain- 
ing normal. Tuberculosis produces a nodular, uneven enlarge- 
ment ; syphilis a smooth, uniform tumor. As a result of 
tuberculosis, inflammatory conditions of one of the testes some- 
times supervene, which generally terminate in suppuration, 
while syphilitic affections of the testes develop without fever 
or inflammation, and very seldom undergo suppuration. At 
the beginning, tuberculosis of the testes, like the syphilitic 
variety, is painless, but later, when the tuberculous affection 
approaches suppuration, the patient suffers severe pain, while 
even strong pressure on the testicle, which is greatly enlarged 
as the result of syphilis, causes no unpleasant sensations. 

It is more difficult to distinguish a recent syphilitic orchitis 
from a commencing cancer of the testicle. 

Both affections develop in the testes, both are at first pain- 
less, and present one or more circumscribed, hard, nodular 
places. But cancerous nodules grow much more rapidly than 
the syphilitic node, and in the former the testis acquires a nod- 
ular surface, while the latter, owing to the fusion of the depos- 
its, becomes uniform and smooth. The longer the carcinoma- 
tous growths last, and the older they grow, the more elastic 
they become; i. e., the less hard they are to the sense of 
touch. Gradual softening and fluctuation of the carcinoma- 
tous kernels ensue, attended by intense, protracted pains, and 
followed by bursting and ulceration. A syphilitic testicle, on 
the contrary, almost always remains stationary in its indurated 
condition, or it disappears almost entirely, and very seldom un- 
dergoes suppuration. In syphilitic inflammation of the testis 
the vas deferens usually remains unaffected, and when it be- 
comes diseased it is transformed into a uniform, thickened car- 
tilaginous cord, while in carcinoma and tuberculosis it, as a 
rule, has hilly or nodular protuberances. Cancer of the testicle 
very often extends to the epididymis, and the retroperitoneal 
glands whose lymphatic vessels emanate from the testis be- 
come involved early (these glands are found on both sides of 
the vertebral column on a level with the kidneys [Albert]). 



SYPHILIS. 269 

The lymphatic glands on the corresponding side usually do not 
become enlarged till the carcinoma of the testis has involved 
the skin of the scrotum ; they then become excessively hyper- 
trophied and transformed into irregular tumors of the size of a 
walnut or hen's egg. In addition, Ricord calls special attention 
to the following very important differential signs : Like carci- 
noma of the breasts or of the eyes, which never occurs in both 
breasts or both eyes simultaneously, always being limited to one 
organ at first, so cancer of the testicle is always unilateral, while 
syphilitic orchitis may occur on both sides at the same time. 

The differentiation between gonorrhceal epididymitis and 
specific inflammation of the testis occasions no difficulties. 
The painful appearance of the affection in the spermatic cord 
and epididymis, accompanied by febrile movement, the swell- 
ing of the testicle in a few days, and, lastly, the presence of a 
blennorrhoea, will be more than sufficient to indicate the true 
nature of the disease. 

Hydrocele and hematocele are even easier to distinguish 
from sarcocele syphilitica than the other varieties. 

Syphilitic inflammation of the testis, according to H. Zeissl's 
observations, is a much rarer disease than specific affections of 
the iris. It hardly occurs once in a hundred syphilitic pa- 
tients. As a rule, it belongs to the later period of the disease. 

The shorter time the disease lasts, and the sooner rational 
treatment is instituted, the sooner a restitutio ad integrum may 
be expected. Like all the other phenomena of syphilis, spe- 
cific inflammation of the testis presents relapses. The worst 
that may be feared from a syphilitic orchitis is the impotence 
of the patient. 

Yirchow, who distinguishes a periorchitis and orchitis syphi- 
litica, ascribes the same role to the tunica vaginalis propria tes- 
tes, in regard to syphilitic affection of the testicle, as the peri- 
toneal envelope of the liver plays in syphilitic hepatitis. Thus 
he found not only cartilaginous thickening and calcification of 
the albuginea testes and tunica vaginalis propria, but adhesions 
between them and complete synechia. Levin found the same 
morbid alterations on the testis which Yirchow described, 
namely, hyperplastic thickening of the albuginea, the septa, 
and the membrana propria of the tubuli seminiferi, targes- 



270 PATHOLOGY AND TREATMENT OF SYPHILIS. 

cence of the veins that inosculate around the tubuli seminif eri, 
adhesion of the naturally isolated seminal canals by new hy- 
perplastic tissue, dark-brown pigmentation, and, lastly, fatty 
degeneration of their epithelial cells. In this manner a con- 
siderable number of the seminal canals are destroyed, and in 
their place fibrous structure is found in the testicle in which 
no tubuli seminiferi can be seen. 

According to Kokitansky, syphilitic inflammation of the 
testis generally attacks with great violence a few lobules at a 
time, and gives rise to immense proliferation of the albuginea 
and the septa, with obliteration of the texture of the gland, so 
that at last it is transformed into an irregular, hard tumor, with 
cheesy, tubercular degenerated foci in which accumulations 
of inspissated pus not infrequently are found. The vas defer- 
ens is here obliterated. In very rare cases gummata of the 
spermatic cord are found, while the corresponding testis is un- 
affected. 

Syphilitic Affections of the Ovaries, Fallopian Tubes, and 

Uterus. 

Yirchow has no doubt that there is an oophoritis syphi- 
litica ; still, he is unable to state whether it produces anything 
more than fibrous induration and its consequences. Xlebs, too, 
is unacquainted with any other lesion in syphilitic women than 
a chronic inflammatory process of the ovaries, which generally 
terminates in speedy shrinking of the organ and the formation 
of circumscribed adhesions. Gummous new growths have been 
observed by Eichet and Lecorche. If both ovaries are affected 
by syphilis, sterility will be the inevitable result. The so-called 
colica scortorum, according to Klebs, may sometimes be due 
to morbid processes in the ovaries. 

In regard to the Fallopian tubes, we know of a case de- 
scribed by Bouchard and Lepine, in which, in addition to 
gummous hepatitis and encephalitis, the tubes were trans- 
formed into hypertrophied cords of the thickness of a finger, 
and contained three soft reddish gummata of the size of a hazel- 
nut on each side. 

In regard to specific diseases of the upper section of the 
uterus, we are unable to speak from personal experience. 



SYPHILIS. 271 

Syphilitic Affections of the Mucous Membrane of the Genital 
Organs of Both Sexes. 

An erythematous redness occasionally develops upon the in- 
ternal surface of the prepuce. In consequence of this a more 
or less severe preputial catarrh is produced, whose secretion 
macerates the epithelial cells of the inflamed membrane. Syphi- 
litic preputial catarrh is distinguished from the common balano- 
postheitis by the fact that it appears in a milder form, usually 
causing no phlegmonous swelling of the prepuce and skin of 
the penis, no acute inflammation of the dorsal lymphatic ves- 
sels of the penis, and no profuse discharge from the fossa coro- 
naria, as in local balanitis. The diagnosis can, however, only 
be positively decided by the presence of other syphilitic mani- 
festations, especially roseola syphilitica on the glans penis and 
the skin generally. 

Syphilitic erythema of the vulva occurs even oftener than 
specific preputial catarrh. Although the affected mucous mem- 
brane is not particularly red nor the discharge profuse, still the 
labia majora and minora are often markedly swollen, and the 
catarrhal redness spreads into the vagina. Erosions may occur 
on the mucous membrane of the vulva and vagina similar to 
those on the prepuce and glans ; these erosions are liable to be 
mistaken by inexperienced physicians for the cause, namely, a 
soft chancre, instead of the effects of syphilis. 

Mucous membrane papules in all their phases alone, or as- 
sociated with erythema of the mucous membrane of the male 
and female genital organs, occur much more frequently than 
erythema of these parts. The papules, being covered with a 
considerable amount of detritus, may readily be mistaken for 
chancroids or new primary syphilitic infecting chancres. The 
best test between both these affections is the speedy or slow 
production of a pustule by inoculation, and the presence or 
absence of other syphilitic secondary phenomena. Mucous 
membrane papules in the male are mostly situated in the fossa 
coronaria, at the aperture of the prepuce and meatus urethrse ; 
in the female, usually at the vulvar orifice. They rarely occur 
higher up in the vagina or on the cervix ; when they occur 
at the latter place they resemble granulations that result from 
uterine catarrh. 



272 PATHOLOGY AND TREATMENT OF SYPHILIS. 

Gummy tumors are found on the inner or mucous surface 
of the prepuce, on the mucons membrane of the labia majora 
and minora, and on the posterior commissure of the vagina, 
either singly or in groups of three or four. In the latter case 
they are apt to become confluent, and form semilunar ulcers. 
They occur less frequently on the cervix, where they are apt 
to be mistaken for a fibroid or carcinomatous tumor. Now 
and then they are seen in the form of urethral or peri-urethral 
infiltration in the male urethra, the caliber of which they are 
apt to diminish, and as a result of disorganization and slough- 
ing may occasion profuse haemorrhage and fistulae of the ure- 
thra. Urethral gummata have been found most frequently in 
the pockets of the fossa navicularis. Gumma of the cervix 
uteri and of the urethra can only be diagnosticated by the aid 
of attending syphilitic phenomena (diseases of the bones) and 
ex juvantibus (administration of iodide of potassium). 

Gummata on the mucous membrane of the genital organs 
of both sexes are very often mistaken for a chancroid or Hun- 
terian primary syphilitic lesion. An ulcerating gumma is dis- 
tinguished from a chancre by the fact that the latter develops 
and approaches cicatrization much more rapidly than the for- 
mer, which is always accompanied by other syphilitic manifes- 
tations, and that it is sometimes semilunar or sickle-shaped. 
The differentiation between a gumma of the genital organs 
and a Hunterian syphilitic primary lesion is only of conse- 
quence because the latter is the alpha and the former the 
omega of the syphilitic disease. 

The disorganization that attacks one part of a gumma 
while healing takes place on the other, and the absence of in- 
filtrated lymphatic glands in the groin, even when the node 
has existed for a long while, will make a differential diagnosis 
between it and epithelial cancer quite easy and certain. 

Syphilitic Affections of the Corpora Cavernosa Penis. 

In several instances we have seen, during the late phases 
of syphilis, cartilaginous indurations, varying in size from that 
of a pea to that of a hazel-nut, originate in the corpora caver- 
nosa, in a painless and apyrexial manner. These materially 
hindered the normal production of erections. The nodes were 



SYPHILIS. 273 

mostly situated in the posterior third of the pendulous portion 
of the penis, and failed to disappear entirely under an anti- 
specific treatment. We have never seen these nodes undergo 
suppuration. 

Syphilitic Affections of the Breasts. 

Sauvages claims to have been one of the first who observed 
in the mammary glands of syphilitic women cancer-like growths 
which were made to disappear under mercurial treatment. 
Richet, Maisonneuve, Hennig, Terneuil, Ambrosoli, and Laug 
have described gummy tumors in the breasts. The two latter 
have also met them in males. Lancereaux distinguishes a dif- 
fused and a gummous mastitis. He records two cases observed 
by Ambrosoli, and one by himself, of diffused mastitis in syphi- 
litic women, which were cured by the administration of iodide 
of potassium. Boeck met with two cases. Both patients had 
suffered for many years from constitutional syphilis. 

Syphilis of the Heart and Blood- Vessels. 

As a result of acquired syphilis, simple callous inflamma- 
tion and gummata develop in the heart in very rare cases. 
The callous inflammations may affect one or all of the layers 
of the cardiac muscle, while gumma almost always attacks the 
myocardium. Gr. Eosenfeld published a report of two pa- 
tients who suffered from " asthma syphiliticum," which greatly 
resembled cardiac asthma. In both cases characteristic evi- 
dences of syphilis of the heart were present. 

Comparatively rare as affections of the heart in consequence 
of syphilis are, so frequent are specific diseases of the blood- 
vessels, and especially of the arteries. The smaller arteries, 
particularly the cerebral vessels, are most frequently affected. 
There are, however, reports of many instances of larger ar- 
teries affected by syphilis, by M. von Zeissl, Yon Langen- 
beck, Kundrat, and Lancereaux. Heubner devoted particular 
attention to syphilitic affections of the arteries. Arteritis 
syphilitica occurs either as an independent process or as part 
of a local specific affection. In the former, grayish-white 
thickening of the intima and adventitia of the arteries is 
found either in a circumscribed form, or the vessels are trans- 
18 



274 PATHOLOGY AND TREATMENT OF SYPHILIS, 

formed into solid cords of connective tissue. In the second 
case, the artery lies in a specific diseased mass, and gener- 
ally all the three coats are involved. Ziegler described this 
process admirably in the following words : " The intima and 
the adventitia are apt to be more affected than the media. If 
the process is still active in the stage of granulation, the thick- 
ened intima will also contain a great deal of cellular tissue. 
Some of the cells are small and round ; some, again, larger, 
spindle-shaped, or stellate, representing various forms of fibro- 
blastema. The same is true of the adventitia. The media 
is only moderately infiltrated with cells. If . the syphilitic 
affection is of older date ; if connective tissue has developed 
in the domain of the inflammation — the hypertrophied coats 
of the arteries will contain more fibrous tissue and fewer cells. 
The media is either in good condition, or it is atrophied and 
fibrous in places. There is nothing peculiarly specific in the 
histological process. But it may be said that in the ordinary 
arteritis of the small vessels, no such enormous accumulation 
of cellular infiltration occurs as in syphilitic inflammation, 
and, especially, that the adventitia is not altered to such a 
degree. The walls of the vessels in syphilis often become 
markedly hypertrophied, sometimes to such a degree as to 
occlude the lumen of affected vessels." Ziegler very aptly 
adds the observation that "no histological criteria of the 
syphilitic process occur in the blood-vessels. Even the rich 
proliferation of cells in the adventitia is not pathognomonic, 
for it is found in the cerebral vessels in other pathological 
conditions, such as tubercles." Syphilis, then, may be regarded 
as one of the most frequent causes of arteritis and its effects. 
By the occlusion of the vessels of an extensive part of an 
organ, serious alterations may be brought about in it. 

Affections of the Brain, Spinal Cord, and Peripheral Nerves, 
as a Result of Syphilis. 

The central nervous system and the peripheral nerves may 
be the site of morbid products engendered by syphilis, or they 
may become involved by affections of structures surrounding 
them (bones, meninges, etc.). As a result of specific exostosis, 
necrosis, and caries of the bones of the skull, violent pains in 



SYPHILIS. 275 

the head, vertigo, jactitation and palsies of the extremities 
may ensue, followed by hemiplegia and secondary grave le- 
sions of the brain and its membranes. The symptoms which 
are produced by the exostosis will, of course, vary according 
to the locality of the brain and spinal cord, which is pressed 
upon. The meninges may be affected by syphilis even in the 
earliest stages without any syphilitic affections of the bones 
being present. In consequence of this meningitis syphilitica, 
the cerebral membranes become thickened, and hemiplegia, 
imbecility, and cortical epilepsy may ensue. This kind of ex- 
tensive thickening of the meninges may terminate in chronic 
inflammation, and engender a series of symptoms which is 
very much allied to progressive paralysis of the insane. L. 
Meyer regards the intimate union of the dura mater with the 
other membranes and the surface of the brain as especially 
pathognomonic of the morbid lesion characteristic of syphilitic 
meningitis. 

As shown by Heubner, disease of the basilar arteries, in 
consequence of syphilis, may be regarded as one of the most 
frequent causes of cerebral affections. It produces grave dis- 
turbances in the circulation in the parts of the brain within 
the sphere of the affected vessels. Sometimes even large cere- 
bral arteries are found totally obliterated. This condition, and 
the thrombosis that follows the constriction of the vessels, 
ultimately result in softening of the brain (encephalitis syphi- 
litica). Grummata, too, are found in the central nervous sys- 
tem, as well as in the peripheral nerves, in the form of large 
or small reddish, yellowish-brown, or gelatinous, transparent 
masses, with cheesy deposits on their margins; or nodes, as 
big as a pea, with cheesy degenerated centers. These products 
have been only recently recognized as syphilitic gummata, 
through the researches of Wagner, Forster, Tumpel, and Reck- 
linghausen. They are found in the most variable parts of the 
brain, in the cortical and white substance, in the corpora quadri- 
gemina and corpus striatum, in the hypophysis cerebri, and also 
in some of the nerves. Of the cerebral nerves the oculo-motor, 
the trochlearis, the abducens, the optic and the facial, are espe- 
cially apt to be affected in consequence of syphilis, and are 
found infiltrated with the yellowish-gray, gelatinous, trans- 



276 PATHOLOGY AND TREATMENT OF SYPHILIS. 

parent, or firm gummatous masses alluded to. On cutting 
them open a few white points can be seen, which were former- 
ly regarded as undestroyed nerve-libers, but which, in reality, 
are nothing more than cheesy deposits. 

In regard to the spinal cord, those diseases must first be 
considered which are caused by the syphilitic affection of its 
envelopes — the vertebrae, and the meninges. As the result of 
exostoses or inflammatory products developed in the vertebrae, 
or marked thickening of the meninges, the entire thickness, 
or only a section of the cord, may become incapable of trans- 
mitting impressions, partly as the result of pressure, partly as 
the result of extension of the inflammation to it, and the well- 
known phenomena of compression-myelitis will ensue. The 
symptoms which appear in such cases vary greatly, according 
to the height of the vertebrae or meninges affected, and ac- 
cording as the process attacks the anterior, lateral, or posterior 
sections of the spinal cord. 

In such cases there occur the so-called root-symptoms, i. e., 
disturbances which originate from pressure upon, or inflamma- 
tion of, the spinal nerve-roots that take their origin from the 
diseased places. In the progress of the disease the symptoms 
of spastic spinal paralysis,* or symptoms of ataxia, or finally, in 
rare cases, so-called spinal hemiplegia may ensue, according to 
the part of the cord that is compressed. Later, certain symp- 
toms regularly appear which indicate a partial or complete 
division of the cord, such as paraplegic conditions, anaesthesia, 
paralysis of the sphincters, and bed-sores. 

In two cases we saw the symptoms of transverse myelitis 
appear at the same time as the secondary phenomena of syphi- 
lis ; they had resisted all kinds of treatment, but finally were 
cured by the use of mercury. There are as yet, to our knowl- 
edge, no descriptions of undoubted pathological facts published ; 
still, the clinical pictures admit of no other conclusion. In 
one case, Seeligmuller, by active antispecific treatment, cured 
a very extensive muscular atrophy in a person suffering from 
syphilis. 



* This term is used here only for the purpose of describing the symptom- 
atology germane to it, and not in the sense employed by Erb. 



SYPHILIS. 277 

Foumier and Erb claim that a causal relation exists between 
tabes and syphilis that has preceded it. In eighty per cent 
of the cases which he has observed, Fonrnier confirmed the co- 
incidence of tabes with syphilis, while Erb cured some and im- 
proved others of his cases by antispecific treatment. The 
question is not yet definitely decided. We are forced, how- 
ever, to side with Westphal, Leyden, and others, against 
Fournier and Erb. In some syphilitic cases certain phenom- 
ena of serious disease of the spinal cord have been observed, 
most frequently symptoms of the so-called ascending spinal 
paralysis (Landry's paralysis), and yet, at the autopsy, not even 
the microscope could detect any abnormal condition of the 
cord. 

The peripheral nerves very often become diseased in con- 
sequence of syphilis. They are affected most frequently by 
the pressure of exostoses, or the thickened meninges, or by 
gummata of the meninges or bones. Thickening of the me- 
ninges at the base of the brain most frequently produces simi- 
lar phenomena, and for that reason paralyses of the muscles of 
the eye are seen so often in syphilitic patients, since the nerves, 
for a long distance of their peripheral course, run close to the 
affected part of the, meninges, and are involved in diseases of 
the latter. Paralysis of the muscles of the eye is a complica- 
tion so common in syphilis that an antispecific treatment should 
be tried in every case. 

In addition to the oculo-motor, abducens, and trochlearis, 
all the other cerebral nerves may become affected by syphilis. 
Primary affection of the nerves occurs less frequently in 
this disease. In the latter, one or more reddish, grayish-red, 
or yellowish foci form on the nerves, which seem to be much 
thicker, but sometimes they atrophy to such a degree that only 
the nerve-sheath remains. The spinal nerves have seldom been 
found affected ; usually they show only secondary changes. 

The diagnosis of cerebral, spinal, and nervous syphilis is 
all the more difficult, because in the majority of cases no symp- 
toms of syphilis in other organs — on the mucous membrane or 
skin — can be discovered. The sudden appearance of a cerebral, 
spinal, or nerve affection, the age and the history, will form 
important guides ; still, not even the good results obtained 



278 PATHOLOGY AND TREATMENT OF SYPHILIS. 

from antispecific treatment will establish the diagnosis beyond 
a donbt. 

Unfortunately, non-specific nervous affections engender 
symptoms similar to those produced by specific diseases. 
From the present standpoint of our knowledge we can make 
the following statement : 

In its first period syphilis produces affections of the me- 
ninges and the basilar cerebral arteries, while the diseases of 
the nervous system that come on later sometimes originate in 
the manner just mentioned, or are due to gummata developing 
in the nervous substance or in the meninges. In general, the 
following groups of symptoms are observed with remarkable 
frequency : Cerebral diseases, consequent upon bone-lesions, 
manifest themselves by fixed violent headache that becomes 
aggravated at night. The painful places are often sensitive 
to external pressure, and upon those places, or near them, 
a periosteal gumma is sometimes found. In quite a num- 
ber of cases cerebral hemiplegias ensue, which are usually 
caused by points of softening that develop in the vicinity of 
a gumma, or as a result of Heubner's disease of the arteries. 
These hemiplegias occur either suddenly, like apoplexy, or 
oftener gradually in successive attacks. The cases belonging to 
the first variety are almost always the result of arterial dis- 
ease, and originate partly from thrombosis, partly from em- 
bolism (as a result of the conveyance of fibrinous coagula 
from projecting points on the walls of large cerebral arteries) 
resulting in sudden plugging of a large vessel. They thus 
give rise to the clinical phenomena of cerebral emboli. Syphi- 
litic hemiplegias not infrequently vacillate in their course, 
sometimes get better and then worse ; often, indeed, they get 
well entirely. This is especially true of the apoplectiform 
cases which have been properly treated by antisyphilitic reme- 
dies. In many cases, again, only a moderate degree of improve- 
ment, indeed, sometimes not even this much, can be achieved 
by similar treatment. In such cases we have to deal with 
plugging of large vessels, which becomes permanent, or with 
softening in the vicinity of a gumma. 

In some cases the manifestations of so-called cortical epi- 
lepsy (Jacksonian epilepsy) are observed in syphilitic patients. 






SYPHILIS. 279 

This affection, as a rule, is either produced by morbid altera- 
tions in the bone (exostoses, gnmmata) or by specific menin- 
gitis. Under snch circumstances the processes mentioned may 
be located in the region of the central convolutions or in their 
immediate vicinity. We then almost always notice attacks of 
convulsions, sometimes with, sometimes without, loss of con- 
sciousness, but in which the spasms differ from ordinary epi- 
lepsy in not attacking the entire muscular system, but only 
groups of muscles. 

It frequently happens that syphilitic patients, after suffer- 
ing from the phenomena already described, or even if they 
have not suffered from them, are attacked by peculiar cephalic 
disturbances which are hardly ever observed in any disease 
but syphilis. They form the so-called " drunken " conditions 
that develop in patients suffering from cerebral syphilis. These 
patients often complain for days and weeks of intense pains, 
numbness, and confusion in the head, before the picture that 
will presently be described develops. They are unable to at- 
tend to their occupations, especially if any mental effort be 
necessary, for the least mental strain aggravates the trouble 
markedly. Having lasted for a while, these symptoms gradu- 
ally grow worse, unconsciousness supervenes, or the cephalic 
disturbances rapidly become aggravated, and then change into 
profound stupor. The patients lie in bed for days with their 
eyes shut, and can only be awakened from their semi-uncon- 
scious condition by being loudly spoken to or shaken. "While 
this condition lasts, they are sometimes perfectly quiet for 
days ; oftener, however, they tug at the bedclothes, play with 
their genital organs, become restless, and get out of bed. 
When roused, they will answer slowly and hesitatingly, often 
manifesting loss of memory and psychical disturbance. Dur- 
ing the time that this condition has been developing, other 
disturbances not infrequently arise, namely, cortical convul- 
sions and hemiplegic phenomena. In quite a number of cases 
the psychical disturbances become aggravated, maniacal symp- 
toms supervene, or the patient becomes comatose. In the 
latter event death is the usual termination. In other cases 
the condition improves, a temporary or permanent cure is 
achieved, but although the patients regain consciousness, they 



280 PATHOLOGY AND TREATMENT OF SYPHILIS. 

are frequently affected with some mental trouble, such as loss 
of memory. At the post-mortem examination of such cases 
Heubner usually found morbid meningeal alterations along 
with the diseased condition of the arteries, and softening of 
the brain depending upon it. 

Lastly, in some cases of syphilis psychical disturbances of 
various kinds have been observed, namely, hypochondria, mel- 
ancholia, chorea with mania (Wunderlich), and other psy- 
choses. 

In regard to the time at which syphilis of the nervous sys- 
tem is likely to appear, it may come on in a very short time 
after infection. In the majority of cases, however, many years 
elapse before it manifests itself. The predisposing causes for 
the development of this form of syphilis, as for all the other 
grave forms, are : too early use of mercury, incomplete treat- 
ment of the disease, excessive indulgence in wine and sexual 
intercourse during the treatment, mental worry, and exertion 
in business. 

A permanent cure can only be achieved when the nerve- 
substance remains unaffected. Improvement takes place rap- 
idly, especially when large doses of mercury and iodide of po- 
tassium are employed. Syphilitic diseases of the nerves require 
a long course of after-treatment to make the cure permanent. 

Syphilitic Affections of the Nose. 

The three cardinal forms of disease already described occur 
also in the nose, but with this difference, that erythema may 
appear on the lower as well as on the upper part of this organ, 
the papules more in the lower part, and the ulcerating nodes 
seem to have a preference for the upper and posterior parts of 
the nasal passages. 

Syphilitic erythema of the nasal mucous membrane, or 
syphilitic nasal catarrh, develops with phenomena which are 
similar to ordinary coryza. It is attended by a sensation of 
tickling, burning, and dryness of the parts ; frequent sneezing 
soon supervenes, and the visible part of the mucous membrane 
is reddened. If the catarrh is limited to the anterior part of 
the mucous membrane the discharge will be only slightly aug- 
mented, but if it spreads to the mucous membrane of the 



SYPHILIS. 281 

higher nasal regions large quantities of thin fluid are secreted, 
causing the patient to blow his nose repeatedly. The discharge 
excoriates the nasal orifices and the adjacent parts. Syphilitic 
nasal catarrh furnishes no pathognomonic symptoms ; its spe- 
cific character can only be inferred from the accompanying 
phenomena and the previous history. It may occur either 
alone or in connection with mucous - membrane papules or 
nodes. In the first case, under appropriate treatment, and 
if the patient takes care of himself, it may disappear tempo- 
rarily or permanently ; in the other event, it may spread to 
the adjacent nasal passages, especially to the lachrymal duct. 
Syphilitic nasal catarrh, if it is limited to the anterior parts 
of the mucous membrane, changes the perception of smell very 
little, while if it involves the superior regions of the nose 
the patients will suffer constantly from a foul odor, although 
the watery nasal secretion and the expired air are odorless 
(JcaJcosmia subjective!). So long as the nasal catarrh is unac- 
companied by any other affection, the air passes through the 
nasal passages unhindered. But if mucous-membrane papules 
or gummata develop, especially in the higher regions of the 
nose, the discharge will gradually acquire a muco - purulent 
character. This thickened nasal discharge readily dries and 
forms crusts and plugs in the passages of the nose as the re- 
sult of the action of the air flowing over them, and thus ma- 
terially impedes respiration. 

The papules are almost always situated upon the lower 
part of the nasal mucous membrane, on the margin of the 
nares, partly on the mucous membrane, and sometimes be- 
come so large here as to actually close up the orifices of the 
nose. "We have already stated that mucous-membrane papules, 
which occur on the mucous membrane of the cartilaginous 
septum, threaten by their disintegration this part of the sep- 
tum {nez cle mouton of the French writers). But whether 
papules and ulcers in consequence of syphilis occur on the 
higher parts of the mucous membrane of the nose, or the de- 
struction of the osseous superstructure only takes place through 
the disorganization of gummata situated at this place, and not 
from the destruction of mucous-membrane papules, can not be 
definitely decided, as it is impossible to obtain' a view of the 



282 PATHOLOGY AND TREATMENT OF SYPHILIS. 

affected parts. The fact that syphilitic affections and de- 
structions of the upper parts of the mucous membrane occur 
chiefly in consequence of inveterate syphilis, and that the ul- 
cers sometimes found simultaneously on other regions of mu- 
cous membrane, or on the common integument likewise, are 
the result of disorganized gummy tumors, proves conclusively 
that the malignant specific affection in the upper nasal regions 
is caused by gummata. 

Rhinitis syphilitica ulcerosa; Coryza syphilitica ulce- 
rosa ; Ozcena syphilitica. The fetid nose (la punaisie of the 
French writers) sometimes begins with the phenomena of a 
catarrhal coryza, or it manifests itself soon by a permanent oc- 
clusion of the nares. In the course of the disease the Schnei- 
derian membrane secretes a large quantity of yellowish or 
greenish, thick, purulent matter. The longer the disease lasts, 
the more ichorous and fetid the discharge becomes, the more 
repulsive is the odor that is diffused from the nose (kakosmia 
objectiva). The foul odor originates from the decomposition 
of animal matter, and reminds one of that caused by fetid per- 
spiration of the feet, or putrid flesh. As the discharge grows 
thicker and more purulent it becomes dry, yellowish-green, 
sticky and fetid, and crusts and plugs form from the nasal 
mucus, pus, blood, and decomposed tissue-elements. These 
close up the nasal passages that are already narrowed by 
the swelling of the mucous membrane, and render respira- 
tion difficult. The patients seek to free these passages by 
violently blowing the nose often, or to remove the obstruc- 
tion with the finger, which is generally followed by slight 
bleeding. 

On examining the nose, the mucous membrane is found 
swollen, and covered with foul-smelling discharge. The ulcers 
are generally situated at the junction of the cartilaginous with 
the bony septum, in which situation perforation of the septum 
most frequently occurs. The opening at first is not bigger 
than a pea or a bean, and is in the bony part of the septum. 
The greater the destruction of the latter the less support the 
bridge of the nose will have ; gradually it sinks in, so that a 
saddle-like depression forms between the tip of the nose and 
the anterior lower border of the nasal bones. 



SYPHILIS. 2S3 

Ulcers that are situated in the upper regions of the nasal 
cavity do not become visible till the triangular nasal cartilage, 
and the skin covering it, have been destroyed by ulceration. 
Generally there is only one ulcer, sometimes two or three; 
they are superficial or penetrate to the bone, which soon at this 
S]^ot becomes carious or necrosed. The necrosis attacks the 
vomer, the perpendicular plate of the ethmoid, the superior 
and middle turbinated bones, sometimes the nasal process of 
the superior maxilla, and the nasal bones. Occasionally the 
ulcerative process spreads from the septum nasi or the choanes 
to the bottom of the nasal cavity, and produces perforation 
of the hard palate, which usually takes place in the median 
line, and sometimes is so large that the base of the cranium 
may be lit up through the opening, and if an ulcer hap- 
pens to be there it will become visible. Moreover, even 
ulcers which originate in the labyrinth of the ethmoid bone, 
fostered by the porous nature of its osseous lamellae, may 
cause so much destruction that the mouth, nasal, frontal and 
spheno-palatine cavities may form one large opening, bounded 
by eroded bony walls, and allowing the movements of the epi- 
glottis to be seen. 

Ozsena syphilitica heals under the following conditions : 
The pain which the patient sometimes suffers on pressure of 
the nasal process of the superior maxilla disappears ; the hor- 
rible odor from the nose and the purulent discharge subside ; 
no more particles of bones come away ; granulations appear on 
the ulcer, and cicatrization takes place by a cellulo-fibrous, 
parchment-like membrane originating on the place where the 
mucous membrane has been destroyed.. The new membrane 
secretes a yellowish substance resembling cerumen. 

Rhinitis ulcerosa develops as a result of acquired and of 
hereditary syphilis ; still, it occurs very rarely in syphilitic in- 
fants. A marked degree of deformity of the nose, and conse- 
quently of the face, is the effect of ozsena syphilitica. If the 
disease is situated in the higher regions of the nose, temporary 
or permanent anosmia may result, the nerves of smell either 
becoming unimpressionable to odors for a long or short time 
by the continuous action of the mephitic nasal discharge, or 
the perception of odors is permanently abolished, because the 



284 PATHOLOGY AND TREATMENT OF SYPHILIS. 

mucous membrane which transmits it is destroyed by ulcera- 
tion and replaced by a dry, parchment-like skin. 

"Whether rhinitis ulcerosa is a symptom of syphilis or of 
scrofula can only be approximately settled by taking into con- 
sideration the coexisting phenomena and the antecedent con- 
ditions. In regard to the concomitant phenomena of ozaena 
syphilitica hereditaria, in the vast majority of cases it is pre- 
ceded by ulceration of the soft palate, while in ozsena scrof u- 
losa neither perforation of the hard nor of the soft palate 
occurs. However, ozaena may also develop secondarily to the 
extirpation or tearing out of a nasal polypus. 

Syphilitic Affection of the Auditory Passages. 

According to Gruber, primary syphilitic disease seldom 
occurs in the external ear. Papular syphilide of the ear and 
external meatus auditorius differs in no way from that on the 
skin. In the deeper part of the external ear, and on the tym- 
panum, it is met with in the form of plaques muqueuses, which 
often can only be distinguished from an otitis externa by other 
signs of syphilis simultaneously present. Exostoses of the 
bony passages are seldom painful, because they grow very 
slowly. According to our observations, nodular syphilides of 
the external ear and meatus occur in both the ulcerating and 
the non-ulcerating forms ; in the former, when it occurs on 
the auricle, it assumes a lupous character (Fournier). Politzer 
also met with pustular eruptions. 

Of all the sections of the ear, the middle ear, owing to the 
frequency with which specific diseases occur in the nasal and 
faucial structures, is most frequently affected by syphilis. In 
the lining membrane of the tympanum, especially in the mu- 
cous membrane covering the membrana tympani, syphilitic 
ulceration very frequently causes severe pains, which, in con- 
tradistinction to ordinary otitis media, do not abate, even after 
perforation of the tympanic membrane has taken place. But, 
so long as the morbid process is confined to the Eustachian 
tube, the patients complain of symptoms that specially belong 
to affections of the auditory nerve. According to Lowenberg, 
infiltrations and proliferations may occlude the faucial aperture 
of the tube, and, if followed by suppuration, occasion fearful 



SYPHILIS. 285 

destruction and retracting scars, that will close up the opening. 
Schwartze regards the following phenomena as characteristic 
of the specific nature of chronic catarrh of the ear: The 
affection is always bilateral, and does not begin for some 
months after other syphilitic phenomena have appeared. The 
nocturnal exacerbations of the osteocopic pains in the tem- 
ples, the rapidly increasing impairment of hearing, and, 
lastly, premature diminution of cephalic bone - conduction 
(labyrinth syphilis), are additional confirmatory evidences of 
the specific foundation of the disease. The extension of the 
suppurative process from the lining membrane of the mastoid 
cells externally to the periosteum of the mastoid process fre- 
quently occurs in syphilitic patients, without perforation of 
the tympanum — i. e., without preceding otorrhoea. Hyper- 
plasia (inflammatory hypertrophy) may be observed on any 
part of the middle ear. Yery severe inflammatory processes 
in the mucous membrane of the middle ear are usually accom- 
panied by hyperemia of the tissues of the labyrinth, which 
causes extravasation of blood, and in this manner engenders 
sudden and usually incurable deafness. 

Syphilitic Affections of the Eye. 

By Professor Ludwig Mauthner. 

Iritis Syphilitica. 

Syphilis per se may undoubtedly occasion iritis, and it is 
equally unquestionable that, of all the causes of iritis, syphilis 
heads the list. We may unhesitatingly maintain that at least 
half, if not a larger proportion, of all the inflammations of the 
iris, is due to syphilis ; indeed, there are medical writers who 
doubt the occurrence of rheumatic iritis, and who are disposed 
to regard all instances of iritis rheumatica as syphilitic. 

Iritis not infrequently occurs in the early stages of syphilis, 
sometimes even as its very first lesion, and in that case dis- 
plays its real character by the visible gummous nodes that 
form in the iris. As these patients were positively treated 
without mercury, we have the best proof that the gummata 
are not the effects of mercurialization. Likewise, the fact 
that, although iritis may appear in the first stage of syphilis, 
yet is also apt to supervene in the later stages, along with 



286 PATHOLOGY AND TREATMENT OF SYPHILIS. 

gummata, proves that, strictly speaking, there are no so-called 
secondary or tertiary manifestations of the disease. 

Syphilitic iritis scarcely ever attacks both eyes simultane- 
ously ; generally, one eye is affected first, and the other after- 
ward. In regard to the symptomatology, it may be stated, 
first of all, that the symptoms of specific iritis can not be dis- 
tinguished, in the majority of cases, from the idiopathic variety. 
Like the latter, it may develop in an acute, subacute, or chronic 
form. 

An iritis that has already developed often remains for a 
long time at its acme. If the affection was ushered in by 
violent pains, that radiated into the eyebrow, into the forehead, 
often over the entire half of the corresponding side of the 
head, and if the symptoms peculiar to iritis (marked injection 
around the cornea, opacity of the anterior surface of the iris, 
change of its color, and blurring of the normal fibers, but espe- 
cially adhesions of the pupillary border of the iris to the ante- 
rior capsule of the lens), accompanied by photophobia, and 
lachrymation have developed quickly, the inflammation will 
be very severe, and may last an unreasonably long while, the 
pains continue undiminished, exacerbating at night, and the in- 
flammatory product, in the form of a membrane covering the 
pupil, and of small nodes situated on the posterior wall of the 
cornea (Descemet's membrane), constantly becomes more and 
more noticeable. 

In other cases, the disease develops less violently ; in still 
others, there is only a diminution of the power of vision that 
induces the patient to seek medical relief. In these cases iritis 
has crept on insidiously, the posterior synechia, the pupillary 
membrane, or little nodes on Descemet's membrane, opposite 
the pupil, that resulted from the disease, have materially dimin- 
ished the power of vision. 

Since the forms of iritis mentioned, as they actually origi- 
nate from syphilis, are not in the least characteristic, and since 
we are unable, by merely examining the eye, to recognize the 
syphilitic basis of the affection, it is of the utmost importance 
for the oculist, in every case of inflammation of the iris, to 
seek for evidences of syphilis — but not in the loose manner in 
which this is usually done. 



SYPHILIS. 287 

However, there is one form of syphilitic iritis which 
proclaims itself as such, namely, iritis gummosa, but which 
scarcely amounts to one fourth of all the cases of specific iritis. 
It is characterized by minute granules, of bright or deep yellow 
(in dark irides, reddish-brown or black) color, which develop 
on the pupillary or ciliary border, or on the plane of the iris ; 
they are generally situated in the parenchyma of the latter, 
project with the smooth, semicircular surface into the anterior 
chamber of the eye, and not infrequently a fine network of 
vessels is woven around them. They vary in size and num- 
ber. There may be several small ones (of the size of a pin's 
head and larger) on various places of the iris, in which case 
the pupillary border will be surrounded by them, like a wreath, 
or only two or three little nodes are seen. However, these very 
isolated granules are the ones that sometimes display such a 
wonderful tendency to proliferate, that they subsequently 
almost completely fill up the anterior chamber. When these 
minute nodes exist, the symptoms of iritis, as a rule, will be 
severe ; sometimes, however, only a section of the iris, in 
which the granules are found, is inflamed, or there are no act- 
ual inflammatory phenomena at all. The microscopical exam- 
ination of these nodes shows the presence of large numbers 
of small cellular elements, such as constitute gummata in gen- 
eral and granulation-tissue. The presence of gummata in iritis 
proves conclusively that syphilis is the primary disease. That 
so many writers should deem iritis gummosa to have so few 
characteristic symptoms, must be due to the fact that, in some 
cases, the clinical history was not investigated with that thor- 
oughness that is often necessary to confirm the presence of 
syphilis. 

In general, it is quite easy to diagnose the gumma-nodes. 
But when, in iritis, a large yellowish-gray lump of inflamma- 
tory product is deposited on the periphery of Descemet's mem- 
brane, it may become impossible to distinguish it from a gum- 
ma situated in the structures of the iris. In that case, nothing 
less than opening the anterior chamber of the eye will solve the 
question, for the deposited matter may then be removed. On 
the other hand, that tumor, which is observed without, but also 
with symptoms of iritis, and is known as granuloma iridis, and 



288 PATHOLOGY AND TREATMENT OF SYPHILIS. 

which, both in its external appearance and histological connec- 
tions, agrees entirely with gumma, will be less likely to deceive 
us in diagnosis. Aside from its extreme rarity, and with the 
exception of another form of node, which may be looked upon 
as a growth of traumatic granulations, it can be regarded as 
nothing else than a true gumma, originating in consequence 
of syphilis, especially the hereditary variety. Equally unim- 
portant, in regard to the diagnosis of gumma, is true tuber- 
culosis of the iris, and the circumstance that, in acute adenitis 
of non-syphilitic origin, small, roundish tumors, of reddish 
color and feeble consistency, are said to occur in iritis. 

Lately, a peculiar, gelatinous exudation, resembling in out- 
ward appearance the dislocated lens, has been seen in the an- 
terior chamber, in cases of iritis. It accumulates with ex- 
treme rapidity and in large quantities, and may disappear with 
equal rapidity. The connection that was formerly claimed to 
exist between this kind of exudation and syphilis can not, how- 
ever, be maintained. 

The terminations of iritis syphilitica, in the main, do not 
differ from those of the idiopathic or rheumatic variety. Un- 
der appropriate treatment it may be cured entirely. Some- 
times this favorable termination ensues even spontaneously. It 
may leave some synechise, with or without a pupillary mem- 
brane. It may cause total closure of the pupil by annular 
posterior synechise, which, since the persistence of synechias 
favors the tendency of the inflammation to relapse, often 
gives rise to secondary glaucoma, and is followed by total 
blindness. 

In regard to gummata, it is necessary to observe that the 
smaller kinds of these structures gradually disappear, and leave 
nothing more than a colorless spot in the parenchyma of the 
iris. In extremely rare cases, small gummata have also been 
seen to undergo purulent degeneration. A large gumma, es- 
pecially if situated on the ciliary border of the iris, may de- 
stroy the eye by attacking the ciliary body. The bulb in 
that case shrinks and becomes totally atrophied. Still, even a 
very large gumma, if it is confined to the iris, may speedily 
and completely disappear, without leaving any injurious ef- 
fects. 



SYPHILIS. 289 

The prognosis of syphilitic iritis should always be given 
with caution — with much greater caution than in idiopathic 
inflammation of the iris. It is necessary to bear in mind that 
the inflammatory phenomena may remain for an unusually 
long time at their height ; that an implication of the other eye 
is at least to be apprehended ; and that the affection has a 
strong tendency to relapse. Thus, it may happen that, although 
the patient is situated under the most favorable circumstances, 
and is undergoing inunction-treatment to the point of sali- 
vation, the iritis that was already cured relapses with terrible 
violence, or the second eye is attacked by the disease in the 
form of grave, gummous iritis ; that the spreading of the mor- 
bid processes from the iris to the ciliary body and choroid oc- 
curs oftener than in any other form of iritis ; and, lastly, that 
the inflammatory product becomes organized into synechial and 
pupillary membranes with great rapidity, and that even an 
early treatment often will accomplish no complete cure. In- 
deed, this may even be true of the other eye, which became 
involved under the observation of the physician. 

The treatment of iritis syphilitica requires not only local 
but also general measures, directed against the primary disease. 
The local treatment, however, differs in no respect from that 
of rheumatic iritis. A few drops of a solution of atropine 
(atropia sulph., 0-05 [gr. j], aq. destil., 5*00 [3iv] should be 
dropped into the conjunctival sac, if the inflammation be se- 
vere, every two hours ; if not, at longer intervals ; and cata- 
plasms of pulv. semini lini should be applied to the eyes. This 
is very agreeable to the patient, and assuages the pains ; if they 
fulfill these ends, it will be necessary to apply them day and 
night. If the pupil does not dilate under this treatment and the 
pains do not abate materially, six or eight leeches should be ap- 
plied to the temples, and a subcutaneous injection of morphine 
administered to the patient in the evening. The action of 
the latter may be prolonged by subsequently giving him a 
dose of chloral hydrate. If the iritis is apparently cured, and 
if no injection of the ciliary body can be seen in the daytime, 
the cornea should be carefully examined when the patient 
wakes in the morning, to see whether any halo is present 
around it. So long as this condition continues, it will be neces- 
19 



290 PATHOLOGY AND TREATMENT OF SYPHILIS. 

sary to use the atropine solution, in order, if possible, to guard 
against a relapse. 

If gumma nodes develop in the course of an iritis syphiliti- 
ca, the physician will feel justified in subjecting the patient to 
mercurial treatment. There is no local, special treatment that 
can be recommended against the gummata : because, on the 
one hand, the small ones are not dangerous to the eye ; on the 
other hand, even a large one may disappear without leaving 
any trace ; and attempts made to obviate any impending dan- 
ger to the eye from a large node by removing it (excising it 
and pieces of iris) have not been followed by satisfactory re- 
sults. 

During the time the severe febrile phenomena last, it will 
be well to keep the patient in a dark room, in bed ; the eye 
(if no cataplasms are employed) should be covered with a linen 
bandage and protected by a green shield ; the patient's diet 
and the movements from his bowels should be regulated. 

If iritis is ushered in under moderate or no symptoms of 
irritation, the local application of atropine, protection of the 
eye against glaring light by the aid of smoky spectacles, and 
avoiding other injurious influences, will suffice. A mercurial 
treatment, however, is perfectly justifiable. 

The treatment of those conditions that may remain after 
the iritis has entirely disappeared belongs to the special do- 
main of the oculist. 

Affections of the Ciliary Body, the Choroid, and Vitre- 
ous Humor. 

The ciliary body scarcely ever becomes affected independ- 
ently unless a primary gumma forms in it. Yet the eye need 
not necessarily be destroyed by the latter condition ; on the 
contrary, gummata of the ciliary body have been seen to dis- 
appear, at any rate, under mercurial treatment, without leaving 
any injurious effects in the eye. 

It is scarcely possible for the ciliary body and choroid to 
become affected by the extension of the inflammation from 
the iris. Acute irido-choroiditis syphilitica, which may super- 
vene, it is true, in some exceptionally rare cases, attended by 
the formation of gumma in the deeper parts of the eye, but, 



SYPHILIS. 291 

as a rule, showing nothing specific, manifests itself in the fol- 
lowing manner : A marked sensitiveness of the ciliary body, 
and remarkable diminution of the tension of the eye-bulb; 
further, a diminution of sight that in no way corresponds to 
the visible opacity of the media ; although the pupil is still 
partly permeable, yet no reflex can be obtained by the ophthal- 
moscope from the fundus of the eye, or the opacities of the 
vitreous humor present are seen as undulating black masses 
in the dim field of vision. These phenomena usually super- 
vene upon a violent iritis. Acute inflammation of the irido- 
choroid structures is a very destructive disease, and when left 
to itself will frequently result in atrophy of the eye. 

In another series of cases of iritis, the attention of the 
physician will be attracted principally by a loss of sight dis- 
proportionate to a complication which he will recognize as 
opacity of the vitreous humor. If the choroid is free from 
morbid alterations (of which we can only convince ourselves, 
as a rule, after the inflammation has entirely disappeared, and 
an iridectomy has been performed), we are justified in assum- 
ing that the opacity of the vitreous humor is not an expression 
of a choroiditis, but that it is an independent inflammation of 
the vitreous body — a hy otitis. This kind of hyalitis may de- 
velop in the course of syphilis even without iritis. Still, the 
fact that alterations of the choroid frequently appear later, 
shows conclusively that it was a case of latent choroiditis 
(serosa). 

The most remarkable specific affection of the choroid, but 
which can only be detected by the aid of the ophthalmoscopic 
mirror, is choroiditis disseminata, of which, in syphilis, the 
small macular form is most frequently seen. However, it does 
not follow that the latter is seen exclusively, or that the large 
macular form does not occur in syphilis. Behind the retinal 
vessels, in the fundus of the eye, there are seen numerous very 
small, roundish, oval or angular, yellowish or bluish-white, in- 
flammatory deposits, surrounded by pigment-cells, especially 
in the equator bulbi. Toward the posterior pole of the eye, 
a few large deposits of exudation, resulting from the fusion of 
a number of small ones, may be seen, or the disease is limited 
to the circumference of the eye. It may also happen that 



292 PATHOLOGY AND TREATMENT OF SYPHILIS. 

bright, pathological foci in the fundus of the eye are entirely 
absent, and in their place the fundus is seen covered with 
irregular clumps, or regular masses of black pigment. Owing 
to the fact that the discolorations in syphilitic choroiditis, as in 
any other kind of inflammation of the retina, are capable of 
assuming figures that strikingly resemble the typical pigment 
degeneration of the retina (so-called retinitis pigmentosa), the 
error has sprung up quite recently of assuming that retinitis 
pigmentosa is a manifestation of hereditary syphilis, or a re- 
sult of constitutional syphilis. In choroiditis disseminata the 
sight is impaired to a variable extent, according to the degree 
in which the external layers of the retina are involved in the 
inflammatory process of the choroid membrane. 

In the treatment of syphilitic inflammation of the choroid, 
mercurial preparations will be required all the more because 
the best results are derived from their use, even in the non- 
specific form of the disease. If the acute irido-choroiditis is 
once subjugated, the sight will materially improve. If re- 
lapses of opacities of the vitreous humor and exacerbations of 
choroiditis disseminata occur, mercury will again be required 
in the treatment. 

Inflammation or the Retina and Optic Neeve. 

Syphilitic choroiditis, like syphilitic iritis, may be com- 
bined with retinitis / the latter, however, also occurs alone, 
and as a rule in the later stages of syphilis. Specific retinitis 
presents no pathognomonic lesions whatever ; still, it can not 
be denied that the symptoms of inflammation in the syphilitic 
form generally do not assume that degree of intensity that 
they do in other kinds of retinitis. As a rule, there are found 
merely light -gray nebular opacities that center around the 
point of entrance of the optic nerve, cover its margins more or 
less, and spread in all directions ; sometimes they are sharply 
outlined, and even at the height of the disease are very slight. 
As the retinal vascular symptoms (varicosities and dilatations 
of the veins) are but slightly marked in most instances, the en- 
tire appearance of the retina might be explained by the tension 
of the delicate membrane of the vitreous body in front of it ; 
but, although a delicate, dust-like opacity is described as an 



SYPHILIS. 293 

early, rarely absent, symptom of retinitis syphilitica, still the 
marked diminution of sight attended by annular defect of 
vision surrounding the point of fixation, and other striking 
disturbances of the functions of the retina, point to the pres- 
ence of grave retinal disease. In other cases retinitis, being 
attended by striking alterations of the structures and vessels of 
the retina, is, per se, easy to diagnose, but its syphilitic founda- 
tion can only be confirmed by the aid of other manifestations. 

As a special form of retinitis that has been met with, com- 
bined with syphilis, the central relapsing variety may be 
mentioned here, which manifests itself by suddenly appearing 
and disappearing, and reappearing again in the same manner, 
as opacities in the domain of the yellow spot, attended with 
corresponding disturbances of vision. 

If gumma nodes develop in the brain in the course of 
syphilis, or the optic nerve undergoes gummous degeneration, 
as has been observed several times, the presence of cerebral 
syphilis, or of syphilis of the optic nerve, may also declare it- 
self by the occurrence of retinitis optica — i. e., by swelling of 
the intraocular portion of the nerve of vision. This form of 
neuritis is not in the least specific ; it only points to the possi- 
bility of the presence of a cerebral tumor, which may indeed 
be a gumma. On the other hand, the use of the ophthalmo- 
scope should never be neglected when the presence of syphilis 
is suspected, because neuritis may come on with very slight 
disturbance of vision, the patient complaining of no fault of 
his visual organ, and yet the presence of a neuritis will mate- 
rially support the diagnosis of cerebral syphilis. After all, 
neuritis and atrophy of the optic nerve occur in syphilis, also 
amblyopia and amaurosis, without any pathological lesion — 
without any coexisting signs of cerebral disease. 

The local treatment of retinitis and neuritis syphilitica is 
limited to keeping off glaring and all kinds of hurtful light ; 
the general treatment is the same as in cerebral syphilis. 

Affections of the Coknea, Conjunctiva, and of the Eye- 
lids. 
Both hereditary and constitutional syphilis find a fertile 
field in the cornea — above all, in the form of keratitis parerb- 



294 PATHOLOGY AND TREATMENT OF SYPHILIS. 

chymatosa (diffusa, interstitialis, profunda). According to the 
views of the English writers, this is the expression of heredi- 
tary syphilis, and simultaneously is said to be present with 
other morbid processes depending upon the hereditary dis- 
ease; for instance, in almost all cases with a peculiar con- 
formation of the teeth (Hutchinson), and in many cases with 
deafness. Still, we may merely assert that parenchymatous 
keratitis is perhaps the ' only affection that in most cases is 
caused by extraocular causes ; that it especially supervenes in 
badly nourished constitutions, and thus occurs alike in chlorotic 
or scrofulous individuals, or in those living in misery and want, 
as well as in syphilis. 

True keratitis punctata, which is characterized by the ap- 
pearance of a dim, grayish spot, as big as a pin's head, in the 
various strata of the substantia propria cornese, has perhaps the 
closest connection with syphilis, but is such a great rarity that 
it only deserves to be mentioned. 

Occasionally we meet in syphilitic persons an obstinate con- 
junctival catarrh that sometimes precedes iritis for a long time. 
Yet it can not be positively asserted that the catarrh, per se, 
was produced by syphilis. Both hard and soft chancres, and 
secondary gummata, are found on the conjunctiva, but all of 
them are exceedingly rare. 

In regard to affections of the eyelids, the most important 
is syphilitic inflammation of the tarsal cartilages. Rosy spots 
or maculae are seen on the external skin of the eyelid ; they 
gradually develop into roundish granules, and when these un- 
dergo degeneration ulcers originate. Ulcers upon the adjacent 
soft parts may also spread to the eyelids. The latter may finally 
become perforated, followed by the formation of scars, which 
cause them to become everted, resulting in cicatricial disfig- 
urement and distortion. 

Affections of the Orbits, Lachrymal Sac, and of the 

Muscles. 

Syphilis may occasion caries, necrosis, and exostosis of the 
orbital bones ; specific ulcers upon the mucous membrane of 
the lachrymal duct, like caries and necrosis of the surrounding 
bony structures, may produce marked constriction of the duct, 



SYPHILIS. 295 

and thus establish a chronic lachrymal disease. Specific in- 
flammation of the muscles of the eye may possibly result in 
paresis of the latter, but as a rule this lesion depends upon 
syphilitic affection of the brain, the affected cerebral nerves 
being compressed at the base of the brain, or involved in the 
morbid process. Here we have isolated pareses or paralyses ; 
still, palsy has been observed in almost all the muscles of 
both eyes. Not infrequently, especially in paralysis of the 
muscles of the eye caused by syphilis, it is possible to confirm 
the simultaneous presence of partial or extensive anaesthesia of 
the skin of the face ; and it can not be denied that the coexist- 
ence of paralysis of the muscles of the eye, and of the parts to 
which the trigeminus is distributed, points to syphilis as the 
primary cause of the disease. 

Syphilitic Affection of the Bones and their Envelopes. 

Next to the common integument and the mucous mem- 
brane, the bones are most frequently subjected to syphilitic 
affections. However, syphilitic affections of the bones do not 
appear till the morbid alterations have intensely and exten- 
sively involved the skin and mucous membranes. Clinical 
experience has shown that superficial syphilitic diseases of the 
skin, roseola, and papules, go hand in hand with periosteal affec- 
tions ; on the other hand, the deep and suppurative lesions of 
the skin, such as ecthyma and rupia, are associated with deeper 
specific parenchymatous bone-diseases (sclerosis and caries pro- 
funda), the gummous affections of the skin or mucous mem- 
brane, with gummata on the skeleton. 

"With the exception of inflammation of the iris, no specific 
lesion of any structure manifests itself by such violent pains as 
affections of the periosteum ; still, the pains vary according as 
the bones are involved from the beginning of the syphilitic 
disease or later in its course. 

The great majority of syphilitic patients complain at the 
beginning of the disease, at the time of the eruptive fever, of 
tearing, dragging pains, which appear here and there, disap- 
pear entirely, and then reappear again, which emanate from 
the periosteum of some of the bones, mostly of the head, 
shoulder, and knee-joints, and especially the cristas tibiaa. 



296 PATHOLOGY AND TREATMENT OF SYPHILIS. 

The painful places are neither swollen, nor is their tempera- 
ture increased ; pressure upon them not only does not increase 
the pain, but generally causes it to disappear. The pains, 
therefore, seem to be purely neuralgic or rheumatoid in char- 
acter. 

The pains which occur later in the course of inveterate cases 
of syphilis, as a rule, are more intense, and do not travel from 
one place to another, because they are due to an exudative 
lesion between the periosteum and bone, or to inflammation 
of the endosteum of the bone cancelli. The patients generally 
describe the pain as deep, boring {dolores osteocopi, terehran- 
tes) ; some maintain that they feel as if the bone were be- 
ing sawed through ; others, again, as if the bone were com- 
pressed in a vise. Syphilitic pains in the bones are particularly 
severe at midnight, disappearing toward morning, attended by 
profuse perspiration ; hence, they have also been called dolores 
nocturni. Ricord denies that an astronomical period exercises 
any influence over them, and asserts that he has found that- the 
exacerbations of the pain are only caused by the warmth of 
the bed. Baumler believes that syphilitic pains in the bones 
are superinduced by nocturnal febrile exacerbations, the action 
of the heightened temperature causing the vessels of the pe- 
riphery of the body, the periosteum, and the bones, to become 
dilated, a larger flow of blood ensues, thus resulting in swell- 
ing of some parts of the bones. According to our experience, 
the nightly exacerbations of pain are not felt by all patients ; 
sometimes the pain in the affected bone is present day and 
night ; sometimes, again, it increases as twilight sets in. The 
latter is always the case when the inflammatory deposits of the 
periosteum or medullary spaces undergo suppuration. Alter- 
nately abating and exacerbating, the pain lasts as long as the 
exudation continues ; it subsides when the inflammatory prod- 
uct becomes ossified, but still continues when suppuration and 
carious degeneration ensue. The cause of the pain in perios- 
titis is the tension of the periosteum by the exudation that is 
poured out between it and the bone ; in ostitis, by the eccen- 
tric dilatation of the medullary spaces, which are surrounded 
by unyielding bone by the new deposit that takes place in 
them. 



SYPHILIS. 297 

Syphilitic Inflammation of the Periosteum; Periostitis Syphi- 
litica. 

Attended by more or less violent pain, a tumor forms on 
some parts of the affected bone. If the finger is gently passed 
over it, the pain is increased ; while, if the pressure is more 
concentrated, it is sometimes diminished. The periosteal swell- 
ing consists of a gelatinous, synovial-like, gummous exudation, 
which, examined microscopically, proves to be jelly-like em- 
bryonal connective tissue. This periosteal inflammatory prod- 
uct is either absorbed or tranformed into pus and ichor — 
periostitis suppurativa sive exulcerativa — or, in consequence 
of a timely deposit of sufficient salts of lime, it becomes ossi- 
fied — ossifying syphilitic periostitis. In the latter case, a por- 
ous bony thickening forms, which, on account of its external 
resemblance to tufa, is also called tophus. But, if the syphilis 
has attained a high degree, the embryonal connective tissue is 
transformed into a gumma or syphiloma — gummous perios- 
titis. 

Ossifying periostitis occurs in a diffuse form or in the 
shape of a smooth, roundish, plano-convex, circumscribed, 
elastic swelling. The skin over it generally remains un- 
affected in its texture, and may be readily displaced. These 
elastic swellings sometimes become very large, but, notwith- 
standing their size, may disappear without leaving a trace be- 
hind, so long as they are not ossified. In many cases, after 
absorption has taken place, the bone retains a cartilaginous 
thickening, due to ossification of the deeper layers of the peri- 
osteum. Ossification usually ensues only in persons of robust 
constitution, especially if the periosteal swellings developed in 
an acute manner. If the periostitis runs a chronic course, 
ossification takes place very slowly. It manifests itself by the 
formation of osteophytes, exostosis, and hyperostosis. The 
new deposits of bony matter, at least at first, are not inti- 
mately and firmly united to the subjacent bone. The neo- 
plasm lies close to the affected bone ; gradually the part of 
the bone in contact with it likewise becomes attacked by an 
adhesive inflammation, on account of which the ossific mat- 
ter of the new deposit and that of the bone blend together. 



298 PATHOLOGY AFD TREATMENT OF SYPHILIS. 

Most of these osteophytes, especially upon the internal or ex- 
ternal surfaces of the bones of the skull, have a smooth, plano- 
convex shape. Such tumors were described by Rokitansky as 
ebony-like exostoses, planted externally upon the superficial 
surface of the bone. They have a well-marked border, and 
often are surrounded by a groove ; in texture, they are more 
dense at the places of contact with the bone, which, however, 
also appear to be indurated. 

Ulcerating periostitis usually announces itself by a circum- 
scribed, painful swelling, which fluctuates from the very be- 
ginning. The skin over it soon becomes red, and fuses with 
the tumor, forming one common swelling. The pus accumu- 
lates between the periosteum and the bone, in such a manner 
that the former is raised up for a considerable extent from the 
bone, and the latter, being thus deprived of its envelope, loses 
its source of nutrition, in consequence of which its upper sur- 
face degenerates into a carious or necrosed condition. Fur- 
thermore, the contiguous soft parts may become involved in the 
suppurative process. There then originates a large, spreading, 
ichorous, phagedenic ulcer of the skin, that extends down to 
the bone. The pus that has formed under the periosteum 
may, however, also become inspissated into a yellowish, caseous 
mass, whereby the periosteal inflammatory product may resem- 
ble tubercular deposit. Exfoliation of necrotic pieces of bone 
occurs very rarely. Finally, after the ulcer of the bone has 
lasted a long while, the wound closes by the formation of new 
connective tissue and retraction of the skin. We have never 
been able to demonstrate the occurrence of suppuration of the 
inflammatory deposits in the parietal layers of the endocra- 
nium. 

Gummous periostitis furnishes, during life, very few diag- 
nostic points. It is not possible to assert positively whether 
the tumor, that has its starting-point in the periosteum, and is 
covered with normal integument, is a growing tophus or a 
gumma. Indeed, even the well-marked, bony hardness of the 
new growth is no proof against the presence of a syphiloma, 
because, as Virchow maintains, it is a question whether a 
gumma of the periosteum may not become ossified. If we 
bear in mind that even the central part of a gumma that origi' 



SYPHILIS. 299 

nates from the periosteum may undergo degeneration, and the 
contiguous bone must afterward become carious or necrosed, 
it is clear that a large number of cases of gummous perios- 
titis should be recorded as ulcerating periostitis. Hence, dur- 
ing life, it is only possible to assert, with approximate cer- 
tainty, after the periosteal swelling has disappeared without 
suppuration, and a depression is felt through the skin in its 
place, that a gumma was absorbed at this point, and that the 
form of bone lesion occurred here which Bertrandi and Vir- 
chow have designated as caries sicca, or inflammatory atrophy 
of the cortex of the bone. There are authentic descriptions 
by Virchow and others which prove, beyond a doubt, that 
papillary structures originating from the periosteum, and con- 
sisting of a transparent, gelatinous, yellowish-gray substance 
grow into contiguous bones, and whenever the periosteum is 
torn off these neoplasms are pulled out of the openings in the 
bones. The microscopical examination of these papillge shows 
that they are real gummata. The gumma that grows into the 
bone gives rise to two apparently contrary processes. While 
the osseous substance disappears from the central point of the 
affected part of the bone, in consequence of rarefaction or 
atrophy, and a funnel-shaped depression is thereby produced, 
new bone substance is deposited on the circumference of this 
depression, upon the surface surrounding it, and in the diploe 
contiguous to the affected places, which becomes indurated or 
eburnated. This hyperostosis forms around the depression a 
slightly irregular, hilly wall, which gradually grows lower and 
smoother till it merges completely into the adjacent normal 
parts. There are frequently cicatricial retractions in the skin 
over the affected bony dej:>ressions. 

The eroding gummata of the bones occur not only on the 
periosteum of the long tubular and flat bones, but also on the 
periosteal layers of the dura mater and on the medullary mem- 
brane. They are met with singly or multiple, in the latter 
case always in groups. Deposits of these gummata are some- 
times found on the internal and external bones of the skull. 
Yirchow has seen several times an external gumma-node cor- 
responding with one internally, and in one case the bone 
became perforated. 



300 PATHOLOGY AND TREATMENT OF SYPHILIS. 

Ostitis Syphilitica. 

In consequence of syphilis, the medullary spaces of the 
bones may be the site of inflammatory deposits, like the gelat- 
inous new growths between the periosteum and bone in peri- 
ostitis, the fine connective-tissue meshes that contain fat be- 
coming generating places for the new growth. So long as the 
neoplastic connective tissue retains the gelatinous composition, 
so long is the affected part of the bone soft, and easily cut 
with a knife. If absorption sets in early, the diseased bone 
again becomes perfectly normal ; if not, the condition of th6 
part gradually becomes altered. The affected part becomes 
sclerotic, like ivory, eburnated, or it degenerates into a state 
of osteoporosis, or is destroyed by suppuration (caries profun- 
da, according to Eokitansky). The favorable termination is 
in osteo-sclerosis, in which the affected bone is both thicker and 
heavier, but not otherwise impaired. The case is altogether 
different with osteo-porotic bone ; this is soft, can be bent, and 
has a markedly waxy color. When it undergoes suppuration, 
the cells and the spaces in the meshes are dilated and filled 
with ichor. The bone is discolored, brittle, or livid, if the 
granulations exuberate in the spaces ; it resembles a putrid 
piece of flesh, and is readily broken down by the pressure of 
the finger, and may be cut with the knife. It has lost its firm, 
cortical substance, and is permeated throughout with pro- 
liferating granulations. In other cases, a new bone has origi- 
nated from the osseous cortical substance, which goes on grow- 
ing, while internally it continues to suppurate, producing an 
appearance as if the carious bone had become inflated. Occa- 
sionally, a circumscribed collection of ichorous matter takes 
place ; it is sometimes surrounded by a hypertrophied osseous 
substance, and is lined internally by a layer of rich vascular 
granulations. The process of ulcerative destruction consists in 
the fusion of the bone-substance with the walls of the medul- 
lary spaces and with the bone-cells, which become dilated and 
filled with a mass of finely granular detritus. The fusion of 
the intercellular substance goes on while the salts of lime are 
being diminished. The marrow undergoes degeneration into 
a fatty ichor, as a result of the destruction of its fatty cells. 



SYPHILIS. 301 

Adjoining the suppurative process of the bone, the soft parts 
are always affected to some extent with inflammation, which 
terminates partly in new hyperplastic deposits, and partly in 
purulent infiltration. The periosteum becomes hypertrophied 
and united to the adjacent connective-tissue proliferations, 
forming a gelatinous or fibrous bulbous mass, infiltrated by 
purulent deposits, in which the muscles are agglutinated. 
The latter grow pale and are destroyed. According to cir- 
cumstances, the purulent collection, in or on the bone, will 
burst externally, sometimes a large ulcer then results, or one 
or more straight or crooked, simple or ramifying long canals 
(fistulse, sinuses) form, in the vicinity or at a distance, whose 
openings are generally surrounded by a rampart of granula- 
tions, or they burrow their way into a joint. The granulations 
have a characteristic appearance, resembling a hen's anus, and 
always indicate the presence of dead bone. 

Gummata occur not infrequently in the medullary spaces. 
Leber t, Rouget, Gosselin, Follin, Virchow, and Chiari have 
seen them in this locality. Thus, necrosis of the bones of the 
skull, in the course of constitutional syphilis, generates pe- 
culiarities which led Virchow to assume that this necrosis be- 
longs to the gummous form. The necrosis here goes on from 
within outward; the dead piece of bone begins to detach 
itself by the formation of an indented line of demarkation 
from the still living indurated bone, the borders of the latter 
frequently projecting over the necrosed piece. Sometimes 
several points of necrosis are met with near each other 
or at remote places ; in the former case they coalesce and cause 
terrible destruction. On its external surface the dead piece 
of bone has large holes, which coalesce inwardly, looking very 
much as if the gumma had originated within it ; but the in- 
closing necrotic substance is at the same time indurated and 
heavy, presenting a most peculiar appearance. 

Chiari has observed gummata in the medullary canal of 
long bones, which, during life, seldom produced any clini- 
cal symptoms. They may be absorbed or cause induration 
of the osseous tissues or central necrosis. Syphilitic affec- 
tions of the bones not infrequently result in spontaneous 
fractures. 



302 PATHOLOGY AND TREATMENT OF SYPHILIS. 



Cicatrization of Syphilitic Ulcers of the Bones. 

Rokitansky and Virchow state that a syphilitic osseous scar 
possesses remarkable peculiarities. According to the former, 
the parts surrounding an ulcer of the bone display not infre- 
quently induration combined with hyperostosis. Virchow de- 
scribes the syphilitic osseous cicatrices in the following words : 
" Every specific scar in a bone is characterized by a lack of pro- 
duction of bone-substance in its center, while a superfluity 
forms at its circumference." If the bone, says Virchow further, 
is totally destroyed at one place, as is often the case in the 
bones of the palate, nasal septum, or of the skull, nothing, or 
at least no ossific matter, will form in its place. Nowhere is 
this so strikingly to be seen as on the skull, where the orifice, 
on its inner surface, is covered with a membrane so capable 
of producing ossification as the dura mater. The latter soon 
thickens at the site of perforation, and when the necrotic 
piece of bone is removed a scar forms, on whose borders the 
external skin, and the soft parts covering the skull, the bone, 
and the dura mater are fused together into a common mass, 
and afterward appears as a white, angemic, dense, thickened 
substance. The longer it lasts the denser and shorter it grows, 
so that the natural arching of the skull at this point disap- 
pears, the entire scar gradually becoming flattened. If the 
entire thickness of the bone is not affected with necrosis, an 
irregular depression will result after the dead piece of bone 
has exfoliated. But little newly formed cicatricial tissue is 
found later in this depression, and the loss of substance here 
is hardly ever replaced by regenerative processes. The only 
sign of regeneration is found at the margins. These, which 
originally were very abrupt, gradually become thinner, and 
subsequently, by the interposition of a bony rind, usually are 
transformed into a space that is permeated by grooves and 
fissures. As induration and hyperostosis of the surrounding 
bony parts regularly take place here, the places resemble very 
much those that have been produced by inflammatory atrophy 
without necrosis or suppuration. 



SYPHILIS. 303 

Site and Effects of Syphilitic Periostitis and Ostitis. 

Any part of the skeleton may become affected by syphilis. 
The cranium, the palate-bones, the clavicles, the sternum, and 
the tibiae are, however, most frequently diseased, probably be- 
cause these parts are more liable to be affected by external 
causes, such as changes of temperature, the air, and especially 
mechanical injuries. Bones with many angles, such as the pha- 
langes, the metacarpal and metatarsal, are very rarely affected. 
Those enlargements of the bones of the pelvis, which at the 
time of Kilian were described as acantho-pelvis or thorn-pelvis, 
may perhaps sometimes originate from syphilis. Periostitis 
and osteomyelitis may occur in the bones that have been men- 
tioned. The diaphyses alone of the tubular bones are almost 
exclusively attacked ; the epiphyses become affected in excep- 
tional cases only, especially in congenital syphilis. The ter- 
minations of periostitis and ostitis vary in different bones. 
Thus ossifying, ulcerating, and gummous periostitis, osteo- 
sclerosis, osteoporosis, caries, and necrosis, occur on the bones 
of the skull, while the intra-maxillary portion of the superior 
maxilla is pre-eminently liable to suffer from suppurative ostitis. 
Specific caries and necrosis seldom originate in the inferior 
maxilla; frequently, however, ossifying or indurating perios- 
titis develops here. 

Some of the nerve or vascular trunks may be compressed 
by osteophytes, whereby neuralgias, palsies, and disturbances 
of circulation will be produced. Thus, we saw the ischiatic 
nerve compressed by an exostosis on the great sacro-ischiatic 
foramen, and the corresponding limb was paralyzed. Paraly- 
sis of the facial nerve and of the corresponding side of the 
face may be produced by an osteophyte near the stylo-mastoid 
process. Again, an exostosis or a gumma on the sella turcica, 
on which the optic commissure rests, will compress the nerve 
of vision to such a degree that the patient may become totally 
blind. Osteophytes and exostoses in the orbit of the eye may 
give rise to exophthalmos. By ossification of the internal 
auditory meatus permanent deafness may ensue. Ossific hy- 
pertrophies on the inner plate of the cranium may, by pressure 
on the brain, produce convulsions, epileptic attacks, and soft- 



304 PATHOLOGY AND TREATMENT OF SYPHILIS. 

ening of the brain. If a gumma over the frontal sinus under- 
goes softening, or if a large or small piece of the cranium at 
this place becomes necrotic, fatal haemorrhage, by opening into 
the superior longitudinal sinus, or meningitis may result. 
Caries of the mastoid process may perforate into the tympanic 
cavity, thereby causing detachment and removal of the ossicles 
of the ear, and this will be followed by deafness. 

Differential Diagnosis of Affections of the Bones produced by 

Syphilis. 

Many of the extreme opponents of the mercurial treatment 
maintain that all the affections of the bones occurring in syphi- 
litic persons are brought about by the use of mercury, and that 
syphilis, per se, is not capable of producing either ostitis or 
periostitis. Still others, who do not deny the existence of 
syphilitic-bone diseases (Mathias), contend that specific affec- 
tions of the bones are a combination of syphilis and mercurial- 
ization — syphilis that has been modified by a treatment with 
mercury. But neither Overbeck's experiments nor Kussmaul's 
clinical observations furnish any evidence that mercurial dis- 
ease of the bones occurs. Mercury attacks only the maxillary 
bones with periostitis and necrosis, and then only in conse- 
quence of mercurial stomatitis, when the mineral was used in- 
judiciously and in excessively large doses, and was followed by 
gangrene of the mucous membrane, and the periosteum of the 
maxillae. There then originate those large, pumice-stone-like, 
porous, hypertrophic growths which are known by the name 
of osteophytes, and differ strikingly from syphilitic affec- 
tions. 

It is impossible to determine at present from an anatom- 
ical standpoint whether any given affection of the bone is of 
scrofulous, syphilitic, or gouty nature ; nor will it ever be pos- 
sible, as Engle says, to characterize any form of osteophyte as 
pathognomonic of this or that dyscrasia. If the disease of the 
bones be not of a gummous character, the clinical physician will 
have to rely upon a number of symptoms to form a diagnosis 
just as he is compelled to do in specific diseases of the skin 
and mucous membrane. The diagnosis is rendered all the 
more difficult by the fact that in many cases most of the symp- 



SYPHILIS. 305 

toms of syphilis are absent, because specific affections of the 
bones very often occur without any syphilitic manifestations 
on the skin and mucous membranes. 

In opposition to this view, Ricord maintains that exostoses 
originating from syphilis oftener affect the upper surface, while 
those resulting from scrofula affect the parenchyma of the bone. 
Rokitansky and Yirchow assert that the plano-convex osteo- 
phyte deposited upon the cranial bones is a form of disease 
peculiar to syphilis. We have already alluded to the fact 
that both of these authors maintain that specific cicatrices 
of bones are peculiarly constituted. In regard to gout or 
rheumatism, we believe that this dyscrasia produces the gouty 
nodes rather upon the small joints — for example, the fingers 
and toes ; and, further, that it deposits its inflammatory prod- 
uct in the form of a powder upon the cartilages of the joints, 
while syphilis affects the shaft of the bone. 

Syphilis of the bones occurs more frequently in women 
than in men ; furthermore, it is a frequent symptom of heredi- 
tary syphilis occurring in youth. 

Syphilitic Affections of the Joints. 

Arthropathies originating from syphilis occur very seldom. 
The few joint affections in syphilitics that came under our ob- 
servation generally attacked the knee and ankle, more rarely 
the acromial joint, and rarest of all the elbow- joint and wrist- 
joint. "We have no positive evidences that syphilis exercises 
any influence in the production of joint affections. Some of 
the arthropathies which we noticed on syphilitic patients were 
recent, appeared in an acute manner, and were attended with 
violent pains ; some consisted of degeneration of the joints, 
hydrarthrosis, tumor albus, and ankylosis. In most cases anti- 
syphilitic treatment exercised no beneficial influence over the 
affection of the joint, while general and local treatment di- 
rected against the presumable underlying chlorosis, scrofula, 
or gout, was crowned with better success. But even those 
affections of the joints which get well under antispecific treat- 
ment afford no proof that they were of syphilitic nature. "We 
are only justified in maintaining that a joint is the site of 
syphilis when it is pathologically demonstrated that the spe- 
20 



306 PATHOLOGY AND TREATMENT OF SYPEILIS. 

cific morbid product of syphilis, gumma, is found in the struct- 
ures entering into the conformation of the joint. Till then 
the occurrence of specific affections of the joints will remain 
doubtful, to say the least. Lancereaux mentions two cases 
of syphilitic affection of the knee-joint in which gumma-like 
tumors were found in the synovial capsule and in the liga- 
ments of the joint. 

Recently many authors — especially Nekton, Lancereaux, 
Chassaignac, Archambault, Loicke, and Erlach, in Berne ; Bergh, 
in Copenhagen; Yolkmann, in Halle; and Taylor, in New 
York — have called attention to a disease of the phalangeal 
joints, originating from syphilis, which has been described as 
dactylitis syphilitica. 

Specific dactylitis occurs in the fingers and toes. The af- 
fected phalanges are markedly increased in thickness, so that 
they are unable to retain their position between the fingers, 
and lie upon their fellows. The swelling, moreover, is not 
only noticeable on the diseased phalanx, but also on the ad- 
joining phalanges. The skin of these phalanges is bluish in 
color, the swelling is tense, and on pressure felt to be elastic, 
but leaves no depression; it is more prominent on the dor- 
sal than on the volar surface of the affected bones. The 
movements of the diseased joints are more or less interfered 
with, and on forcible motion crepitation may be felt in the 
joints ; active movement is almost impossible. The pain even 
on pressure is generally slight. In those cases that came un- 
der our observation, the first and second phalangeal joints were 
most frequently involved ; the metacarpo-phalangeal joint not 
so often. 

Syphilitic dactylitis is due to gummous deposits in the sub- 
cutaneous connective tissue, periosteum, bone, and the textures 
entering into the formation of the joint. The diagnosis of the 
specific origin of this affection can only be firmly established 
by the previous and present history, and the result of treat- 
ment. In most cases an appropriate treatment will bring 
about complete recovery ; sometimes there results a pyoar- 
throsis, or the disease terminates in atrophy of the diseased 
phalanx, while the integument, joint, and tendons remain 
normal. 



SYPHILIS. 307 

Syphilitic Affection of the Cartilages. 

The cartilages of the nose, eyelids, and larynx, in conse- 
quence of syphilis, may undergo the same kind of morbid al- 
terations, attended by suppuration, as are observed on the con- 
tiguous skin and mucous membrane. If only a small piece of 
mucous membrane overlying the perichondrium is destroyed, 
the affected cartilage will be perforated at that point, as is the 
case with the cartilage of the septum nasi ; or if the cartilage 
itself is attacked, a piece of it will slough away by carious ul- 
ceration, as is often seen to occur on the epiglottis. In either 
event the rest of the cartilage suffers no textural changes. 

The case is altogether different with the thyroid cartilage 
— here perichondritis and ossification of the cartilage likewise 
take place without inflammation. The larynx loses its natural 
elasticity, and pressure on the lateral surfaces of the thyroid 
cartilages causes pain. Aside from the fact that in perichon- 
dritis the mucous membrane of the larynx is markedly swollen, 
the aryepiglottic ligaments degenerate into fibrous welts, the 
vocal cords become thickened, and thus lose so much of their 
mobility that, on account of the ossification of the thyroid car- 
tilage, the laryngeal cavity is no longer surrounded by elastic 
but by tense walls, thus causing marked interference with 
phonation. Caries or necrosis of the thyroid cartilage in con- 
sequence of syphilis occurs very seldom. But if ulcers form 
in the broad part of the mucous membrane, corresponding to 
the cricoid cartilage, the part of the cartilage that has become 
denuded will become ossified and carious. If the caries then 
attacks the upper border of the cricoid cartilage itself, the 
joint connection with the arytenoid cartilage is destroyed, the 
latter ossifies, and then likewise becomes necrotic. The adhe- 
sions on the cricoid and thyroid cartilages then become so 
feeble that one of the arytenoid cartilages may be coughed up, 
or an abscess forms in the vicinity through which the cartilage 
is expelled. If the abscess encroaches upon the cornua of the 
hyoid bone, the latter will also become necrotic and expelled 
through the aperture. This kind of degeneration and destruc- 
tion of the cartilages of the larynx may also originate from 
laryngeal tuberculosis. 



308 PATHOLOGY AND TREATMENT OF SYPHILIS. 

Syphilitic Affections of Muscles, Tendons, and Sheaths of 

Tendons. 

Disease of some of the muscles is a painful and not infre- 
quently a grave affection that occurs in the later stages of 
syphilis. Specific disease of the muscles is sometimes accom- 
panied by pains like those of muscular rheumatism. The pains 
gradually increase in severity till they attain such an intensity 
that the muscles become perfectly rigid and immovable. They 
are then in a state of constant contraction. The pains in some 
parts of the muscles will be considerably aggravated by con- 
tact. They often subside, but increase in severity when at- 
tempts are made to extend the limb forcibly. 

The disease of the muscle results from a chronic local 
inflammation of the muscular sheath, in which a circum- 
scribed hypertrophy caused by proliferation of connective tis- 
sue ensues, so that the primitive muscular fibers are destroyed 
and absorbed. At the places where the muscular structure is 
destroyed, the connective tissue that proliferates from the peri- 
mysium may, under certain circumstances, according to Nek- 
ton, increase to the size of a hazel-nut or hen's egg, and con- 
stitute a gumma. Contrary to Nekton's statement, however, 
we were seldom able to discover a muscular node by the sense 
of touch ; nor, as a rule, did we find any change in the color of 
the skin over the affected parts. 

The morbid alteration is usually situated in the belly of the 
muscle, but is said to occur likewise in the tendinous part. 
According to our observations, syphilitic contractures took 
place in the vast majority of cases in the biceps brachii, next 
in the biceps femoris, once only in the left sterno-cleido-mas- 
toid, in consequence of which collum obstipum originated. 

There are some cases of strabismus occurring in syphilitic 
patients which may not be due to peripheral or central affec- 
tion of the nerves of the ocular muscles, but to gummous 
alterations in the ocular muscles themselves. Nekton has 
seen gummata in the biceps brachii, pectoralis major, mas- 
seter, in both gemelli, in the rectus abdominis, and in the 
semi-membranosus. 

We once saw a patient in whom gummous tumors formed 



SYPHILIS. 309 

in the peroneus of the right leg and in the tibialis posticus of 
the left leg. The tumor of the tibialis posticus diminished 
markedly in size after the internal use and local application 
of iodides. The gumma in the peroneus degenerated and 
broke through the skin, spreading downward till it reached 
the corresponding malleolus. 

Syphilitic muscular disease, when recognized early and 
treated rationally, lasts only a short time ; left to itself it will 
last a much longer time. If the connective tissue which pro- 
liferates into the muscular fibrillse is absorbed, the affected 
muscles may be completely restored and capable of perform- 
ing their function ; but if the morbid lesion has lasted for 
a long while, the muscle becomes atrophied and forever re- 
mains contractured. Specific muscular tumors may become 
soft and break through the skin above them. It is claimed 
that restitution of the muscle is possible even after the skin 
has been ruptured, if the morbid changes of the muscle do 
not extend too deeply. In the latter event, the muscle in- 
variably atrophies. 

There is no doubt whatever that the sheaths of the tendons, 
like any other organ or part of an organ, may become affected 
by syphilis. 

Diseases of the tendinous sheaths are, however, very rare, 
few instances being recorded in medical literature. In the 
year 1868 Yerneuil reported the occurrence of serous effusion 
into the tendinous sheaths of the extensors of the fingers in 
syphilitic patients. In Yerneuil's four cases, all of which were 
observed in women, the affection of the tendinous sheaths 
occurred simultaneously with the outbreak of secondary mani- 
festations. There was considerable exudation, but it never ex- 
tended to the forearm ; it fluctuated distinctly, and the swell- 
ing was sharply defined ; the skin was not changed. Fournier, 
commenting on the report of Yerneuirs cases, says that he has 
seen six cases of this kind, and thinks the disease is of fre- 
quent occurrence. This author met with syphilitic affections 
of the sinews and tendinous sheaths on the extensor muscles of 
the toes, on the tendo- Achilles, on the biceps of the upper and 
lower extremity, on the supinator longus, peroneus, etc. Ac- 
cording to Fournier, " painless tumors with marked exudation 



310 PATHOLOGY AND TREATMENT OF SYPHILIS. 

occur ; but sometimes inflammatory phenomena, attended by 
redness of the skin, are present. In other cases, little or no 
fluctuation is felt, the tumor is doughy, or the affection can 
only be recognized from the impaired function of the muscle 
and painfulness of a tendon on pressure. Gummata have also 
been observed on the sheaths of tendons. Thus, Baumler men- 
tions a case reported by Nunn, in which a pale, yellowish tu- 
mor, half the size of an orange, formed in the tendons on the 
dorsum of the foot, in a person forty-five years of age, who for 
twenty years had suffered from syphilis. It was expelled by 
suppuration through the skin — a similar one having been ex- 
pelled in the same manner, some time previously, from the 
sinews on the side of the knee." Chouet, in his valuable 
work, also describes a case of a gumma which developed in 
the tendinous sheath of the anterior peroneus muscle of the 
right side. The gumma underwent degeneration and slough- 
ing. This lesion appeared fifteen or sixteen years after the 
person became infected. We saw in a person affected with 
syphilis bilateral hygroma of the forearms, corresponding to 
the common extensors. 

Syphilitic Affection of the Bursse. 

We have never had an opportunity of seeing an undoubted 
case of syphilitic affection of the bursse ; hence, we can only 
refer to the writings of other specialists upon this specific 
affection. Keyes, for the sake of analogy, divides syphilitic 
affections of the bursse into the secondary and tertiary forms. 
He has never seen a case of secondary bursitis with or without 
exudation into the bursa ; still, he thinks the existence of this 
lesion, comparing it to other similar affections of the joints 
and of the tendons, is very probable. Allusions to the occur- 
rence of secondary syphilitic bursitis without effusion are 
found in the writings of Jules Yoisin, Fournier, and Adolphe 
Yafner. Gosselin, Fournier, and Verneuil have described graph- 
ically inflammation of the bursa with effusion. Secondary 
syphilitic inflammation of the bursa causes little inconvenience, 
and may therefore easily be overlooked. Tertiary affections of 
the bursa, on the contrary, are not so unusual. According to 
Keyes, it is not possible to divide them into the gummous and 



SYPHILIS. 311 

hyperplastic forms, as there is no proof of the occurrence of 
the latter. All the known cases are of the first form. There 
are no post-mortem observations of this disease. From a 
clinical point of view, however, two kinds of gummous bur- 
sitis may be distinguished : One occurs by the extension of 
the disease from adjacent tissues ; the other originates in the 
bursa itself. Keyes relates fourteen cases — seven of which are 
not yet reported — of tertiary, specific bursitis. In twelve the 
bursee were primarily affected. The bursse in the vicinity of 
the knee were affected eight times ; those over the patella on 
both sides, in three cases ; on one side, in two cases ; over the 
tuberosity of the tibiae, in one case ; between the insertion of 
the semitendinosus and the lateral ligament of the knee-joint, 
each one — upon both sides alike, and upon one side alone. In 
the other four cases, the bursa was affected on one side only 
over a malleolus, under a corn, in the palm of the hand, and 
over the olecranon process. Both sexes are equally affected 
by it ; but, in all of the six women, the bursse of the knee 
only were diseased. The average age of the patients was 
thirty-five years. The shortest time that elapsed between the 
occurrence of the chancre and that of the bursitis was one and 
a half year ; the longest, eight and a half years. In half of 
the cases, an injury was found to be the causal factor that 
started the lesion. In all cases the disease ran a painless 
course till the skin became involved. Fluctuation could only 
be detected in some cases, and then indistinctly. Antisyphi- 
litic treatment generally brought about a rapid recovery — in 
all, marked improvement. For further information, we refer 
the reader to the works of Chouet and Yiday. 

Endemic Syphilis ; Leproid or Syphiloid Disease. 

During the last century, and until quite recently, attention 
was attracted to a peculiar form of disease that appeared like a 
pest in various parts of Europe and America. Sometimes this 
was regarded as a modification of leprosy (lepra seu elephantiasis 
grsecorum), and then again as a degenerated syphilis ; and, ac- 
cording to the relative view of the matter, was described either 
as leproid or syphiloid. These forms of disease were popu- 
larly designated according to the place or province where they 



312 PATHOLOGY AND TREATMENT OF SYPHILIS. 

occurred inost frequently. Thus, in Norway and Sweden it 
was called " Badesyge " (from rada, bad, miserable, and syge, 
pest) ; in other places — the Holstein, the Ditmarsian, or 
marsh — the Jutland disease ; in the Austro-Hungarian Empire, 
SherVvejo or Scherlievo, after a village in Fiumaner County. 
There are still other synonyma : mat di Fiume, di Fueine, 
mat di Bagussa, di Breno, Falcadine. It was also spoken 
of as Lithuanian or Courlandian and Hessian syphiloid. In 
Servia the disease belonging to this group was called Frenga ; 
in the Bukowina, in Liebenbiirgen, in Koumania, Boala ; in 
Greece, " Spirokolon, orchida, and FrangoP In French Can- 
ada it was known by the name of mal de la Bay de St. Paul, 
mal Anglais, maladie des ehoulements, the Ottawa disease, 
and as Canadian syphiloid. In Scotland syphilis occurring 
endemically was described as siavvin, sibben, or sibbens, owing 
to the resemblance of the moist cutaneous nodes, which the 
evil engendered, to a cluster of Scottish strawberries, which in 
the Celtic dialect is called sivvin. On closer investigation 
these endemic diseases proved, in the vast majority of cases, 
to be hereditary and acquired syphilis ; but especially the in- 
veterate and neglected variety, the so-called tertiary manifesta- 
tions. In addition, many other ordinary chronic diseases of 
the skin, such as chronic eczema, lupus, psoriasis, etc., were in- 
cluded. These endemics of syphilis were soon subjugated by 
the sanitary regulations that were established for the control 
of the patients, and by hospitals, where the disease was treated 
by antisyphilitic remedies. 

[Malignant or Galloping Syphilis. 

By the term malignant or galloping syphilis (already al- 
luded to on page 172) is meant a form of syphilitic disease 
that runs an exceedingly rapid course, but which differs very 
little from ordinary syphilis in the essential features of the 
fundamental malady. The lesions of the different manifes- 
tations present only the characteristic trait of running an ex- 
tremely rapid course. Ordinarily, the morbid phenomena, 
after the acute stage of the eruption has passed, lapse into a 
markedly chronic condition, but in the galloping form the 
disease retains its acute character, and the eruptions that f ol- 



SYPHILIS. 313 

low succeed one another very rapidly, so that the lesions com- 
monly denominated tertiary appear within a few months from 
the time the patient became infected. The secondary period, 
which ordinarily lasts two and three years, is here only of short 
duration ; indeed, in some cases no secondary phenomena are 
noticeable at all, the very first eruption being tertiary in char- 
acter, the disease sometimes overleaping the secondary and 
lapsing into the tertiary stage in perhaps three months from 
the time infection took place. 

None of the constitutional phenomena of malignant syphi- 
lis, including the primary initial lesion, display any marked 
deviation from the corresponding manifestations of cases that 
run an ordinary course. Neither the site nor the formation of 
the initial indurated lesion, neither a gangrenous, nor any other 
peculiarity of the chancre, has any effect in producing this 
form of syphilis. Even the first eruption usually presents 
nothing peculiar, though the one following may assume a ter- 
tiary character. In some cases, again, the first general mani- 
festation of the disease may be a pustular eruption and the 
efflorescences, instead of desquamating and healing, are rapid- 
ly converted into ulcers. In that case the ulcerating tertiary 
syphilides differ from their prototype of ordinary syphilis by 
appearing in greater numbers, the entire body being cohered 
by them. They vary greatly in form, and are more confused 
and irregular in the cases that run a rapid course. Gummata of 
the skin are seldom or never seen early in malignant syphilis, 
a circumstance that is easily explained by the rapid course of 
the disease, and by the great tendency of the morbid product 
to undergo suppuration. Specific affections of other organs, 
of the mucous membranes, bones, viscera, etc., present as lit- 
tle diversity in malignant syphilis as the morbid products 
of those organs in cases that run an ordinary course, differ- 
ing only as regards the time of their appearance. There is 
but one symptom that is pathognomonic of this variety of 
syphilis, namely, the occurrence of febrile phenomena pre- 
vious to the outbreak of each successive eruption, while in 
ordinary cases the several eruptions are not generally ushered 
in by fever. 

The most important feature in the course of galloping 



314 PATHOLOGY AND TREATMENT OF SYPHILIS. 

syphilis, as already intimated, is the early appearance of what 
has been denominated tertiary phenomena, and the total ab- 
sence or brief duration of the secondary stage. But as the 
lesions of syphilis have been arbitrarily classified, and no 
symptom or group of symptoms is indicative of the stage of 
the disease, it is impossible to draw a line between the cases 
that run a normal and those that run a rapid malignant course, 
according to the period that has elapsed from the time infec- 
tion occurred till the appearance of the first eruption. Still, 
it will not be amiss to consider those cases in which tertiary 
manifestations appear in the course of the first year as belong- 
ing to the galloping or malignant variety. It will also be self- 
evident that, when the disease runs such a rapid course, the 
various manifestations will be complicated by preceding and 
subsequent morbid phenomena. Hence we have in galloping 
syphilis new outbreaks of eruptions before the preceding ones 
have been cured, and these eruptions or the lesions of the vis- 
cera always manifest the late character of the disease. 

Notwithstanding the rapidity of the course and the severity 
of the various manifestations that characterize malignant syphi- 
lis, instances have been known in which the subsequent out- 
bursts of morbid phenomena occurred at longer intervals, the 
eruptions were less severe and fewer in numbers, the succeed- 
ing efflorescences being papular and segregated instead of ul- 
cerating and aggregating ; and, finally, even this galloping ma- 
lignant syphilis seems to have run its course, and the disease, 
like an extinct volcano, has apparently died out. 

In regard to the diagnosis there is nothing in the phe- 
nomena of galloping syphilis that is likely to render it more 
difficult than in ordinary cases. Indeed, the multiplicity and 
profuseness of the eruptions, and the severity of the ulcera- 
tions are apt to render it all the more easy. But in regard to 
the prognosis the case is altogether different. It is evident 
that the terrible and frequent eruptions, the intensity of the 
ulcerations, the recurrence of the febrile phenomena, must ulti- 
mately exhaust the patient and terminate in death. Another 
circumstance that adds to the gravity of the prognosis in ma- 
lignant syphilis is the danger to the internal organs, especially 
the brain, which may be attacked early in the disease ; some- 



SYPHILIS. 315 

times, indeed, before the expiration of the first year. Such 
cases usually terminate fatally (Fournier). 

In regard to the causes that will produce galloping syphi- 
lis in a certain class of patients, little definite is known. There 
is good authority for saying that the malignant or galloping 
form was quite common when syphilis first appeared epidemi- 
cally ; it is now, however, quite rare. Unquestionably it de- 
pends upon certain conditions of the constitution of the patient 
for its production — cachexia, 'alcoholism, depraved habits, 'or 
the like — and which render the system less able to resist the 
virulency of the syphilitic poison on the one hand and less 
amenable to treatment on the other. Still, I can recall two in- 
stances where none of these conditions obtained, both patients 
being entirely free from any discoverable taint that could have 
served as a cause for the production of this form, since they 
were middle-aged, well-developed men with good previous 
histories. 

The results of the treatment of this particular form of 
syphilis may be readily inferred from its character. It is ex- 
ceedingly obstinate to treatment, and successful results are ob- 
tained in exceptional cases only. The exhaustion consequent 
upon the extensive drain upon the system from the numerous 
and severe ulcers, the debilitating intercurrent febrile attacks, 
or the speedy encroachment of the disease upon some of the 
important viscera, will nullify the physician's efforts and 
hasten the fatal end.] 

Hereditary Syphilis. 

By the term hereditary syphilis is meant that species of 
syphilis that is inherited from syphilitic parents by the progeny 
begotten by them. Hereditary syphilis is mainly characterized 
by the fact that the individuals affected by it never present 
any primary specific lesion. In the majority of cases heredi- 
tary syphilitic children are born with the evidences of the dis- 
ease, or the manifestations develop during the first few weeks 
of extra-uterine life. Generally, the signs of hereditary syphi- 
lis appear during the first three months after birth. In very 
rare cases the symptoms do not come on till the time of pu- 
berty of the unhappy victim, this form being designated by 



316 PATHOLOGY AND TREATMENT OF SYPHILIS. 

the term syphilis hereditaria tarda. Hereditary syphilis may, 
therefore, be subdivided into two varieties, viz. (1) syphilis 
hereditaria prcecox (which appears a short time after birth), 
and (2) syphilis hereditaria tarda (which does not appear till 
a long time after birth, usually at the period of puberty). 

In regard to the theory of inheritance, we may, relying 
upon our experience and that of other authors, lay down the 
following aphorisms : 

1. If one of the parents is syphilitic at the time the child 
is procreated, it may be syphilitic. 

2. There are cases in which syphilitic parents, even while 
still manifesting evidences of recent syphilis, procreate healthy 
children. 

3. "When a mother, healthy at the time of procreation, 
gives birth to a child who has inherited the disease from the 
father, the mother will suffer from latent syphilis at the most, 
because till now only three cases are known of mothers be- 
coming infected by the hereditarily syphilitic children whom 
they suckled. (The infection of the mother by a syphilitic 
child, through the placental circulation, according to Ricord 
and Diday, is called choc en retour.) The circumstance that 
mothers never, or very seldom, are infected by their own 
children during wet-nursing, is now known as Colles's law. 

4. If both parents were sound at the time of procreation, 
and the mother acquires syphilis during pregnancy, the child 
may, after being begotten, become syphilitic. The later in 
the period of gestation the infection of the mother occurs, the 
more probable is it that the child will remain well, because 
the contagium of syphilis has a shorter period in which to ex- 
ercise its effect upon the child. This kind of infection of the 
children is called infectio in utero (Kassowitz), or, according 
to Yajada, post-conceptional humoral infection. The placenta 
is no obstacle to the passage of the contagium from the mother 
to the foetus, or the reverse. 

5. The more recent the syphilis in the parents, the more 
probable is it that the child will be infected, and the graver 
the manifestations in the latter are apt to be. Generally, the 
infants are still-born, or come into the world bearing specific 
manifestations. 



SYPHILIS. 317 

6. If the disease in the parents is latent, the child will de- 
velop syphilis a long time after its birth. Grave forms of the 
disease are then rare, still they are not always absent in chil- 
dren of such parents. 

7. The longer the time which has elapsed after the specific 
symptoms in the parents have disappeared, the less probable 
is it that they will beget syphilitic children. 

8. In the majority of cases, syphilis in the parents gradu- 
ally grows feebler, so that, after begetting some syphilitic chil- 
dren, they finally procreate healthy ones. 

These aphorisms are the conclusions of our experience. 
No infallible dogma for hereditary syphilis and its dissemi- 
nation, however, can be laid down, and we and others have 
certainly met with exceptional cases, which will afford food 
for thought concerning the dissemination of the disease. No 
doubt that, by closer observation and more accurate knowledge 
gained concerning heredity in general, the mystery that still 
envelops much that is strange and hidden in the study of this 
chapter of syphilis will be solved, and the progress of science 
in the future will find the key to these problems. 

In regard to the influence that syphilis exercises upon preg- 
nancy, it may be premised that the foetus very often dies in 
utero very early, and then the macerated foetus {infantes semi- 
cocti), presenting the appearance of having been scalded, is 
aborted. Whether the death of the foetus is the result of dis- 
ease of the foetus itself, or of the uterus and placenta, has not 
yet been definitely decided. Pollnow regards hydrops sangui- 
nolentus as an intra-uterine disease of the foetus, and heredi- 
tary syphilis as one of the most frequent causes of it. Barnes 
thinks that syphilis engenders a morbid condition of the uter- 
ine mucous membrane — a chronic inflammation — and since the 
placenta which develops from the latter is the organ through 
which the foetus derives its nutriment, the latter must natu- 
rally die when its fountain of nutriment is diseased. Yirchow 
found morbid alterations in the maternal part of the pla- 
centa that reminded him strongly of gummous tumors {en- 
dometritis 'placentaris gummosa). Frankel has also demon- 
strated, in the fetal part of the placenta, a degeneration pro- 
duced by cellular proliferation of the placental follicles, which 



318 PATHOLOGY AND TREATMENT OF SYPHILIS. 

may cause compression and obliteration of the follicular ves- 
sels, and finally terminate in fatty degeneration and atrophy 
of the placental follicles. Oedmanson found, in five cases of 
abortions produced by syphilis, alterations in the umbilical 
vessels and in the placenta. The umbilical vessels presented 
atheromatous inflammation of their walls ; in the main branches 
thrombi were found constituting the picture of interstitial pla- 
centitis. H. Zeissl noticed that the placentae of syphilitic 
women are comparatively smaller, feebler, and wilted, fatty, 
pale, and friable ; the surface facing the uterus presents small 
or large spots of so-called hepatization, which, in the upper 
strata, are infiltrated with calcareous incrustations. 

Children, who are overcome by the syphilitic diathesis 
during intra-uterine life, are either born with the manifesta- 
tions of the syphilis, or the latter appear in the first few days 
after birth. However even children begotten by fathers suf- 
fering from latent syphilis may come into the world apparently 
well, and remain well during early infancy. Later we notice 
the gradual formation of infiltrations (falsely called lupus 
syphilis hereditaria) upon some parts of the skin, with simul- 
taneous destruction of the soft palate and the nasal bones 
(ozwna syphilitica), the occurrence of hyperplasia on the 
cranial or tubular bones, etc. ; phenomena which formerly, 
even more than now, were deemed evidences of scrofula. 
Hence, as has been remarked, a congenital syphilis may be said 
to occur which manifests itself in utero, or a few days after 
birth, and an inherited syphilis, which casts off its mask later 
during youth. If syphilitic phenomena appear in a nursling 
several months after birth, such as we see in the first phases 
of acquired syphilis, they should not be regarded as the results 
of inherited syphilis, but of syphilis acquired per partum or 
postpartum. 

In regard to mothers who give birth to children with he- 
reditary syphilis, we wish to add, that Hutchinson believes 
that repeated bearing of syphilitic foetuses gradually engenders 
a specific poisoning of the mother, and that the consequences 
of this poisoning often appear very late, in which case they 
manifest themselves at once as tertiary phenomena. Baren- 
sprung maintains that the semen of a syphilitic man, which, 



SYPHILIS. 319 

under ordinary circnmstances, is innocuous for the woman, 
will infect her as soon as he impregnates her. "Women who, 
at the time of conception, are affected with recent syphilis, 
seldom give birth to a viable foetus ; they generally abort or 
miscarry at the beginning of the eighth month or earlier. Ac- 
cording to Whitehead, four per cent of syphilitic infected moth- 
ers abort. We can not confirm the views of Mayer and Bednar, 
that all mothers affected with constitutional syphilis are abso- 
lutely sterile ; still, H. Zeissl met with many cases of women 
suffering from internal syphilis who were unfruitful. He saw 
women who had no signs of syphilitic primary lesion, or any 
specific exanthema, affected with periostitis and falling out of 
the hair, and with intense anaemia, which phenomena disap- 
peared upon antisyphilitic treatment. He believes that in 
these cases the semen of the syphilitic man was the medium 
of infection of the woman. 

Manifestations of Congenital Syphilis. 

Congenital syphilis engenders morbid alterations similar to 
those produced by the acquired form. Infants affected with 
marked hereditary syphilis at the time of birth are, as a rule, 
badly nourished ; the skin generally, and that of the face espe- 
cially, is wrinkled, giving them the appearance of a weazened, 
marasmatic old man. 

The morbid alterations of the general skin resemble very 
much the analogous eruptions of acquired syphilis in the adult. 
According to our experience, however, congenital syphilis of 
the skin appears only under three main forms, namely, macu- 
lar, papular, and bullous syphilide. We never saw rupia, ecthy- 
ma and cutaneous nodes in infants. 

As a sign of hereditary syphilis manifesting itself in the 
earliest period of infancy, Hutchinson mentions the peculiar 
curving of the upper incisor teeth ; this lesion is said to be 
due to a faulty development of the dental sacs that keeps pace 
with the general atrophy of the body. As a consequence, the 
permanent incisors remain short and narrow, being wide at the 
base, and their angles rounded ; their lower borders are deeply 
indented in the center ; they have a dirty-yellowish color, and 
seem to be semi-transparent. Similar signs, if they appear on 



320 PATHOLOGY AND TREATMENT OF SYPHILIS. 

the other teeth, are said to be of no diagnostic value. We are 
not inclined to attach much importance to them. 

Macular Syphilide in the Infant; Erythema Maculo-papulatnm 
Syphiliticum Neonatorum. 

This syphilide generally develops in the first weeks of in- 
fancy, if the new-born child does not come into the world with 
it. A late appearance of macular syphilide in the infant always 
indicates that it was not infected in utero, but outside of it, post 
jpartum or per partum. Macular syphilide of the new-born 
presents the same characteristics as its prototype in the adult, 
originating through acquired syphilis. Most of the spots that 
attract attention are situated on the sides of the thorax, be- 
coming sparser toward the sternum ; they are never seen on 
the neck and face ; a few occur on the forehead where the 
hairs cease to grow. 

If the affected child is not treated promptly and judiciously, 
other syphilitic phenomena quickly make their appearauce on 
different parts of the body. Flat, copper-colored nodules, as 
big as a lentil, then form on the palms of the hands and soles 
of the feet, and on the heels, and soon become covered with 
yellowish scales, which may be easily pulled off, or excoria- 
tions and fissures (rhagades) originate on the places mentioned, 
especially on the heels. Frequently the grooves near the alee 
nasi are remarkably red, and covered with fine, whitish scales, 
while mucous-membrane papules are present at the angles of 
the mouth and nasal orifices, upon which the mucus has dried 
and formed crusts. These kinds of humid cutaneous or mu- 
cous-membrane papules form in the folds of the buttocks, in 
the hollow of the knee, at the anus, scrotum, and in the genito- 
crural folds of both sexes. The papules that are met with on 
the latter places soon lose their caruncular condition, from 
causes already mentioned, and are then likely to be mistaken 
for intertrigo. The denuded corium on these places secretes 
a yellowish, glutinous fluid that speedily putrefies. In many 
infants, erythema maculo-papulatum syphilitica appears, as in 
the adult, on the internal surface of the prepuce, on the glans 
penis, and on the labia minora. Or circumscribed dark spots, 
varying in size from that of a lentil to that of a bean, occur on 



SYPHILIS. 321 

those places, which become excoriated by catarrh of the glans 
or of the vulva (that is frequently present), and are transformed 
into bright red abrasions. 

In some cases, a few solitary lenticular papules are found 
among the roseola-spots, mostly on the elbow and on the in- 
ternal surfaces of both thighs. We never saw macular syphi- 
lide on the new-born or nursling without the simultaneous 
presence of moist papules on some places, for instance on the 
anus, labia majora, angles of the mouth, and between the toes. 
The cervical, axillary, and other glands seldom swell up to 
such an extent in consequence of syphilis congenita in the in- 
fant as in the adult. 

So long as no phenomena of suppuration supervene, macu- 
lar syphilide in the new-born child runs an apyrexial course. 
We can recall but one case of recovery of a child affected with 
syphilis congenita maculosa. All the others became anaemic, 
and terminated their miserable existence in about two or three 
weeks, from complications with exhausting diarrhoea, bron- 
chial catarrh, or pneumonia. 

Papular Syphilide in the Infant. 

We found that papular syphilide, in its various metamor- 
phoses, occurs less frequently than the macular form in the 
new-born, and, in regard to location, succession to and combi- 
nation with other syphilides, it behaves precisely as does its 
prototype in the adult. We have rarely seen the so-called 
papulo-miliaries or lichen miliaries syphilitica as the result 
of congenital syphilis. In children who do not bring papules 
into the world with them, the eruption will not develop simul- 
taneously on all the places where they usually occur ; this 
accounts for the finding on such infants of young and old 
papules. 

In rare cases, the papules are grouped together so closely, 
on some places, that their scales form an almost unbroken 
coat-of-mail. Most of the scales, in the two cases that came 
under our observation, occurred on the back, sides of the 
chest, on the palms of the hands and soles of the feet, and, in 
part, on the forehead and nape of the neck. 
21 



322 PATHOLOGY AND TREATMENT OF SYPHILIS. 

Pustular, Gummous, and Hemorrhagic Syphilide in the Infant. 

We observed pustular or bullous cutaneous affection in the 
new-born more frequently than papular syphilide. Infants 
either bring it with them into the world, or they become 
affected by it during the first week after birth. In the latter 
case, brownish-red spots or papules, varying in size from that 
of a lentil to that of a pea, slightly elevated above the level of 
the skin, are found on the forehead, especially near the eye- 
lashes, in the face, now and then on the chin, on the buttocks, 
on the extensor and flexor surfaces of the extremities, and, in 
greatest numbers, on the palms of the hands and soles of the 
feet. Within three or four days, most of these spots and flat 
papules are changed into flabby pustules, containing yellowish- 
green, thin pus, of the size of a pea and larger. The pustules 
are not perfectly round; here and there, especially on the 
palms of the hands and soles of the feet, they are indented 
and irregular, as the result of the coalescence of several ag- 
gregated efflorescences. The center of the pustules collapses 
speedily, whereby the umbilicated depression ensues. But, 
while the central depression of the cover of the pustule dries, 
and forms a thin crust, the remaining purulent contents raise 
the contiguous epidermis, and the pustular wall that has not 
yet dried is thereby increased in circumference. The red- 
dened cutis beneath the thin crust is found somewhat injured, 
as in varicella and impetigo of the nursling and adult, but by 
no means very seriously. This is a somewhat hastily sketched 
morbid picture of the cutaneous disease which is generally 
described as pemphigus syphiliticus neonatorum, a synonym, 
which H. Zeissl deems incorrect, since neither transparent 
vesicles form, nor, as in pemphigus foiiaceus, do the contents 
of these blebs, that speedily become opaque, wash away the 
epidermal covering, resulting sometimes in the exposure of a 
large extent of inflamed cutis. H. Zeissl therefore deems it 
more correct, in accordance with the laws of analogy, to de- 
scribe the eruption under consideration as varicella syphilitica 
confluens neonatorum, because in the latter, as in the confluent 
varioloid syphilide of the adult, an umbilicated depression of 
some of the pustules containing thin pus, recurs. 



SYPHILIS. 323 

Severe excoriations generally occur on the heels as an ac- 
cessory phenomenon in the bullous or pustular syphilides of 
the new-born. The nasal cavities of most of these infants 
gradually become occluded by the drying of the secretion of 
the Schneiderian membrane, in consequence of which breath- 
ing through the nose becomes difficult, if not impossible — the 
little patient being obliged to gasp for breath, and unable to 
suck the breast. If the precarious existence of a new-born 
child affected with pustular syphilide is prolonged for a fort- 
night or more, paronychial swellings will form on some of the 
ungual joints of the fingers and toes ; most of these swellings 
begin to suppurate near the matrix of the nail, whereby the 
latter is subsequently cast off. We have never seen onychia 
sicca in children afflicted with hereditary syphilis. The same 
is true of the falling out of the hair and eyebrows as a result 
of syphilis congenita. 

Pustular syphilide is attended by a rapid pulse, and for 
that reason the patients are very restless. All infants affected 
with this syphilide that came under the care of H. Zeissl (most 
of them foundlings) died before they attained the age of two 
or three weeks ; those that were born with the eruption seemed 
even more wretched, and succumbed in a week. Those that 
are attacked by the bullous form frequently die in utero. 

It is very difficult to distinguish between the pustular 
syphilide and pemphigus cachecticorum of the new-born. The 
only sign by which, according to our observation, these two 
cutaneous diseases can be distinguished from each other is, 
that in pemphigus cachecticorum the bullae dry, form crusts, 
and exfoliate much more quickly than in pemphigus syphiliti- 
cus. After pemphigus cachecticorum has formed crusts and 
exfoliated, the former efflorescence quickly becomes covered 
with a new epidermal layer, while the pustules in the so-called 
pemphigus syphiliticus are more persistent, and after they have 
exf oliated new skin very seldom forms upon them ; nor do any 
new pustules originate in the former on the places where some 
had already been located. While all the new-born children 
afflicted with syphilitic pemphigus that came under our ob- 
servation died, those suffering from the cachectic form some- 
times recovered under good nursing and care. 



324 PATHOLOGY AND TREATMENT OF SYPHILIS. 

In infants we very rarely saw impetiginous or the so-called 
crustaceous syphilide in the form of small, impetiginous crusts 
on the scalp. We have not met with acne syphilide, ecthyma, 
or rupia in the new-born as a result of syphilis ; on the other 
hand, in the few cases of rupia in grown-up children that 
came under our observation, we could always detect the spot 
where the infection took place, and thus prove that the child 
acquired syphilis after it was born. From personal experience 
we feel equally justified in denying the statement that vesicu- 
lar syphilides, such as herpes and eczema syphilitica, ever occur 
in infants. 

We have repeatedly seen nodular syphilide, or suppurat- 
ing or perforating tubercles, as a symptom of hereditary syphi- 
lis, but only in children several years of age, in the form of 
nodes that became transformed into confluent serpiginous ul- 
cers. This lesion never occurs in the form of scattered nodes 
in the new-born or nurslings. 

So far we have met with no cases of syphilis hemor- 
rhagica, such as have been reported by Baltz, Behrend, Deah- 
na, and others. Hemorrhagic syphilis, according to Behrend, 
is a peculiar morbid alteration in the circulatory apparatus 
which occurs almost exclusively in inherited venereal disease ; 
Baltz is the only one so far who has described a few cases 
that have been observed in the adult. It is characterized by 
ecthymous eruptions on the skin, in the subserous tissues and 
the meninges of the brain ; and probably also in the paren- 
chyma of the organs ; furthermore, by haemorrhage from the 
navel, after the cord has fallen off, so that we may have pur- 
pura and omphalorrhagia syphilitica, in combination or sepa- 
rately. Either may occur with profuse bleeding from an acci- 
dental injury, or from the apparently sound mucous membrane 
of the mouth, nose, or intestinal canal. 

Behrend regards the marked fragility of the blood-vessels 
and diminished coagulability of the blood as causes of the 
bleeding which is produced by syphilis. Hsemorrhagic syphi- 
lis is not identical with haemophilia, for the latter represents 
a permanent diathesis that will last through life ; the former, 
a transient haemorrhagic diathesis. 



SYPHILIS. 325 

Syphilitic Affections of the Mucous Membrane in the Infant. 

In congenital syphilis, as in acquired syphilis of the adult, 
the mucous membranes are affected mostly in those parts that 
are visible. Accordingly, the nasal mucous membrane, espe- 
cially at the margin of the nares, the mucous membrane of the 
mouth from the red border of the lips to the fauces and 
larynx ; furthermore, the mucous membrane of the anus and 
genital organs — where it merges into the common integument 
— will be affected. Of all the places the lips, especially the 
angles of the mouth, are the most frequent sites of specific 
affections ; next to this the isthmus f aucium, the tongue, the 
internal surface of. the cheeks, and the lips ; furthermore, the 
mucous membrane covering the cartilaginous part of the nasal 
septum. We have never seen any syphilitic diseases on the 
posterior wall of the fauces, pharynx, and the higher regious 
of the nasal passages in infants and older children. Very 
frequently, on the contrary, the mucous membrane covering 
the vocal cords and Morgagni's cavity of the larynx is swollen 
and diseased — a condition which, owing to the inaccessibility 
of the parts, is only detected by the crying of the infants, 
who then emit peculiar piping-shrill tones. 

The morbid alterations of all the parts just mentioned 
manifest themselves by permanent redness, erythema, or by 
the formation of scattered or confluent papular inflammatory 
foci. The epithelial cells on the papular inflamed spots are 
either pearly-white, the opacities disappearing if the papules 
are absorbed, or if they degenerate and suppurate the epithelial 
cells are destroyed, whereby the affected places are transformed 
into erosions that bleed readily or into superficial ulcers. Sup- 
puration ensues on the places that are most exposed to press- 
ure or friction — thus, on the lips, at the angles of the mouth, 
and at the margin of the anus. At these places the denuded 
swollen cutis generally cracks, and then quite deep fissures and 
rhagades form. These bleeding crevices become covered with 
crusts composed of blood and matter, and render sucking and 
defecation painful. This process recurs on the tonsils, uvula, 
and palatine arch. 

In the nursling we have seen vegetations (pointed condy- 
loma) occur only on the mucous-membrane papules at the anus. 



326 PATHOLOGY AND TREATMENT OF SYPHILIS. 

We have only seen gummata, and deep ulcers resulting from 
them, in the mucous membrane of the mouth, fauces, and nasal 
cavity — -never in that of the rectum or external genital organs. 
Once we observed deep ulcers in the tonsils in coexisting gum- 
ma of the tongue. 

Syphilitic affection of the nasal mucous membrane — coryza 
syphilitica neonatorum — originates in the following manner : 
The nasal mucous membrane, especially that of the cartilage of 
the nasal septum, becomes markedly red and slightly swollen. 
Occasionally the epithelium even here is opaque or abraded, 
and at first secretes a profuse but thin mucus, which gradu- 
ally becomes thicker, yellowish, purulent, and finally ichorous. 
The mucous membrane of the nasal tracts is eroded by the 
irritating discharge and bleeds easily, the discharge becom- 
ing streaked with blood. Like the mucous membrane of the 
septum, the margin of the nasal orifices and the skin of the 
upper lip become excoriated. The thicker the discharge, the 
larger the amount of blood that exudes, and the greater the 
number of blood-coagula, the more will the already swollen 
nasal passages become narrowed, so that the little patient is 
almost totally unable to breathe with the mouth shut. Suck- 
ing the breast then becomes an unspeakable torture, as the 
occasionally coexisting affection of the tonsils itself renders 
that process exceedingly difficult and laborious. We have met 
but one case of the sinking in of the bony nasal framework by 
preceding necrosis of the vomer or ethmoid. ]STo case of stink- 
nose (punaise) in the new-born came under our observation. 
Some years ago J. Neumann published the report of an au- 
topsy on an infant that died from congenital syphilis, and in 
whom the ethmoid was destroyed, and the bony framework of 
the nose had collapsed. 

All or some of the morbid alterations of the mucous mem- 
branes, just described, very seldom occur alone ; in most of the 
cases, they accompany the morbid lesions of the common integu- 
ment, already described above. 

Syphilitic Affections of the Bones and their Tunics. 
The skeleton of children suffering from hereditary syphilis 
may not only be attacked by those diseases of the bones with 



SYPHILIS. 327 

wliicli we became acquainted in studying the lesions occurring 
in persons with acquired syphilis, but in addition it is subject 
to most remarkable and characteristic morbid alterations. The 
latter consist essentially in a disturbance of the normal growth 
of the bones of the infantile skeleton, and represent sometimes 
atrophic conditions of the pre-formed cartilaginous and osseous 
substance, and again of new growths of the bony structure. 
The most frequent, and probably the earliest, bone-affection 
which is caused by hereditary syphilis is disease of the epiphy- 
sis of the tubular bones, such as the cartilage-bone junction of 
the ribs. Wagner, Waldyer, and Kobner maintain that this 
process is especially pathognomonic of the intra-uterine origin 
of syphilis. Kobner regards it even as a new pathological dif- 
ferential sign between the latter and acquired syphilis of young 
children. These authors invariably found in all the congeni- 
tally syphilitic children dissected by them, even in abortions 
of the seventh month, the alterations of the ossification bound- 
aries of the tubular bones and ribs. Even when the altera- 
tions seemed to be macroscopically absent, which was seldom 
the ease, they could be positively diagnosed microscopically. 
In most cases gummata were found simultaneously in the in- 
ternal organs, and mucous-membrane or cutaneous syphilide, 
and syphilitic lesions in the placenta were also present ; but, 
even when all these were absent, the bone-cartilage boundary 
was sufficiently marked. These observers saw macroscopically 
all the stages of those alterations from the simple spreading of 
the cartilage proliferation-zone and the spongy layer of Guerin ; 
from the irregular, shaggy encroachment of the ossification-zone 
and of the cartilage up to the total detachment of the epiphysis, 
by a widened yellowish zone between the calcareous cartilage 
and the grayish-red, pulpy substance developed from the spongy 
portion of the bone. The microscope shows, on the cartilage- 
bone boundaries, that the young medullary spaces are choked 
up with granulation-tissue, consisting of small, round, or angu- 
lar and spindle-shaped elements, mixed up and attached to one 
another by prolongations. In addition, we find sometimes a 
thick, sometimes, again, in case the epiphysis becomes de- 
tached, a semi-fluid substance like a sub-periosteal gummata ; it 
never becomes purulent, as Wagner claims, nor is it devoid of 



328 PATHOLOGY AND TREATMENT OF SYPHILIS. 

vascularity. The second characteristic which they discovered 
is the extremely imperfect development of the osteoblasts, de- 
scribed by Gegenbauer and Waldyer — large, multiple-shaped 
cells ready to become ossified, which in the normal bone are 
found in a continuous layer like epithelial cells, but occur here 
singly and very imperfectly developed. In their place small 
granulation-cells, or long, spindle-shaped elements, are present. 
In addition to these constant alterations periostitis ossificans 
was found in the vicinity of the epiphysial boundary, though 
only in the most advanced cases. Waldyer and Kobner de- 
scribe this lesion as syphilitic granulation-growth. 

The inflammatory disease of the " growing cartilage," ac- 
cording to Parrot, produces those peculiar pseudo-paralyses, 
which sometimes occur in the extremities of children afflicted 
with syphilis congenita. The causes of motor disturbances are 
the suppurating processes resulting from an abscess situated 
above or below the joint, and which separates the epiphysis 
from the diaphysis, though the nerves and muscles remain 
totally uninjured. In addition to the epiphysial detachment 
mentioned by Lewin, C. Pellizzari and Tafani speak of fract- 
ures and infractions in the diaphysis of the ribs, and Par- 
rot describes erosions and perforation of the skull (craniotabes 
and plagio-cephalia). 

New growths of bony substance and osteophytes occur 
especially on the lower epiphysial ends of the long bones, and 
on the cranium in the vicinity of the anterior f ontanelle (Par- 
rot's natiform skull). 

It is easy to comprehend how the disturbances of nutrition 
in the growing bones, caused by hereditary syphilis, may be 
one of the causes of rachitis. 

Affections of the Eye in Consequence of Hereditary Syphilis. 

Ophthalmo-blennorrhoea very often occurs in children who 
suffer from congenital syphilis ; it sometimes originates when 
the catarrhal process of a syphilitic coryza is transmitted through 
the lachrymal ducts to the conjunctiva of one or both eyes. 

Whether that lesion in which the remnants of an irido- 
choroiditis that has run its course in utero — namely, the union 
of the iris and cornea, the latter being covered more or less 



SYPHILIS. 329 

with organized material, and intercalar staphyloma — are found, 
should be described as the effects of hereditary syphilis, is a 
mooted question even among oculists. Equally uncertain is 
the question regarding the connection of keratitis parenchy- 
matosa in infancy and youth with hereditary syphilis. Ocu- 
lists speak more positively regarding the occurrence of iritis 
ex syphilide hereditaria. The diagnosis is based upon the 
marasmatic condition of the infants, upon the protracted char- 
acter of the disease, its tendency to form synechia and occlu- 
sion of the pupil, and upon the extraordinarily rare occurrence 
of ordinary iritis in childhood. 

Morbid Alterations of the Internal Organs resulting from 
Hereditary Syphilis. 

The most constant and frequent alterations resulting from 
hereditary syphilis are found in the liver. Schott describes 
the liver in syphilitic new-born children as follows : "It is 
usually enlarged, dense, reddish, or yellowish — hence, on in- 
cising it, it is seen to be speckled in some places ; the outlines 
of the acini are obliterated in most cases, but the incised tissue 
was found uniform ; the more dense and doughy incisions were 
glossy and lardaceous. In another case there was found, in 
the hepatic parenchyma, over the large vessels, a roundish, 
yellowish, white, dense node as big as a pea, around which 
whitish welts ramified in different directions." 

In regard to the forms of syphilitic affections of the liver 
in the infant, Schott says further : " "While the forms of he- 
patic syphilis in adults vary, perihepatitis, accompanied by 
lobulation of the liver, or interstitial hepatitis, or, lastly, gum- 
mous nodes being present, in children with hereditary syphilis^ 
we find hardly anything beyond induration, seldom any nodes ; 
still, even when nodes are present, we can not always safely con- 
clude that the case is one of syphilis, since other processes, such 
as effusion of blood in the liver, may also occasion them." 

We, too, have seen repeatedly in the liver of syphilitic chil- 
dren, sharply outlined, yellowish- white nodes as big as a hazel- 
nut, proliferation of connective tissue, and cicatricial retractions. 

Many physicians look upon an enlarged spleen as an im- 
portant clinical symptom denoting hereditary syphilis. Klebs 



330 PATHOLOGY AFD TREATMENT OF SYPHILIS. 

found, in the pancreas of a foetus six months old, a number of 
gumma-nodes, and syphilitic lesions in the lungs, liver, and 
kidneys. Further, he mentions a case of syphilis in the infant 
described by Cruveilhier, in which the pancreas was trans- 
formed into a white, dense, lardaceous mass ; at the same time 
gumma-nodes were present in the thymus gland and white 
syphilitic pneumonia was noticed. In twenty-three cases of 
disease of the epiphysial margin of the bones and enlarge- 
ment of the spleen, Birch - Hirschf eld found the pancreas 
affected thirteen times. The morbid lesion consisted of pro- 
liferation of the interstitial tissue and atrophy of the glandu- 
lar parenchyma. 

Olivier, Cruveilhier, Forster, and Wagner saw, in the lungs 
of infants who died from syphilis, lobular indurations which, 
when cut into, were found to be yellowish, red, or gray in 
color, the center being cheesy ; these indurated deposits were 
pronounced by them gummata or syphilomata. "We, too, have 
seen similar indurated spots of the size of a hazel-nut in the 
parenchyma of the lungs in the cadavers of syphilitic infants. 
Diffused syphilomatous infiltration may extend over both lungs, 
or affect half of one lung, or even less. The infiltrated places 
are destitute of air, reddish-gray or yellowish-gray, smooth, ho- 
mogeneous, and secreting a meager amount of opaque fluid, the 
bronchial tubes are normal in width, filled with air and puru- 
lent mucus, the mucous membrane is pale and thickened, and 
the bronchial glands hypertrophied. Under the microscope 
the inter-alveolar tissue is seen to be dilated by a deposit of 
atrophied or fatty degenerated cells and granules, albumen, 
and fat-molecules ; between these is found a slight amount of 
homogeneous basement substance. The mucous membrane of 
the small bronchi is uniformly infiltrated with a deposit of 
cells and nuclei, and in some places there are elevations with 
broad bases. The pleurae of syphilomatous lungs are gen- 
erally normal ; the pulmonary tissue is firm, heavier, and only 
slightly dilatable. Kobner and "Waldeyer have also noticed, 
in the lungs of hereditary syphilitic patients, numerous nodu- 
lar gummata and diffused, inter-alveolar, small-celled granula- 
tion-proliferations. 

Klebs thinks that intra-uterine renal syphilis is not infre- 



SYPHILIS. 331 

quent, and lie describes a case of this kind in which gnmmous 
deposits, containing granular tissue that had been transformed 
into spindle-cells, were found in the kidney. 

Virchow claims that he has seen several times, in congeni- 
tal syphilis of the new-born, enlargement and fatty degenera- 
tion of the supra-renal capsule. 

In the cadaver of a boy six days of age Forster observed 
fibroid degeneration of Peyer's intestinal glands, which he 
presumes was the effect of hereditary syphilis. These glands 
projected above the level of the mucous membrane, the pro- 
jection increasing toward the center of the plaque ; the color 
was grayish-red, the upper surface dense and glossy. On sec- 
tion, the thickened patches were found to be hard, glossy, and 
gray, and could not be torn off from the unaltered muscular 
coat. The ulcers extended to the upper end of the ileum. 
Higher up ulcers in groups of twos and threes were found of 
four to six millimetres in length, while those in the ileum 
were mostly eight to twelve millimetres in length. The ul- 
cers were oval or round ; here and there they displayed a tend- 
ency to form a ring. There were no normal Peyer's patches 
to be seen. Simple inflammatory swelling of the solitary fol- 
licles, but no ulcers, were found in the colon. The mesenteric 
glands, and the small, firm spleen, were normal. The micro- 
scopical appearances were as follows : The hypertrophied pro- 
jecting plaques consisted only of a dense network of connective 
tissue, which extended as a uniform layer from the upper 
surface to the muscular coat, and was quite poor in cells and 
granules. In the center of the plaque, where it appeared 
rough, the connective tissue broke down into a mass of finely 
granular detritus. The villi ceased at the borders ; the cylin- 
drical and lenticular glands were entirely absent. 

Poth describes similar appearances found at the autopsy of 
a child ^.yq clays old. 

Schott states that he found, in the cadaver of a child that 
died with pustular syphilide, tumefaction of the intestinal 
glands, similar to that observed in scarlatina, typhoid fever, 
and, in rarer cases, in leukeemic conditions. 

Mracek found syphilitic affections of the small intestines 
in ten out of nearly two hundred cases. There were either 



332 PATHOLOGY AND TREATMENT OF SYPHILIS. 

diffused inflammatory or typical syphilitic lesions, and the lat- 
ter were partly in the form of infiltration around Peyer's 
plaques, partly in the form of irregularly scattered nodes and 
granules. 

In both forms there were infiltrations of small cells into the 
intestines, the hyperplasia starting from the adventitia of small 
arteries. The occlusion of the caliber of the canal, caused by 
these infiltrations, interfered with a proper blood-supply to 
the part, and resulted in the degeneration of the deposits and 
nodes by anaemic necrosis. 

In the brains of the cadavers of children that succumbed 
to congenital syphilis, and were examined by Schott, only one 
kind of alterations was found, namely, gelatinous tumors as 
big as a hazel-nut beneath both anterior lobes. A microscopi- 
cal examination proved that their structure was similar to that 
of the tumors described by John Miller, and which Wagner 
found in the vicinity of the corpora quadrigemina in a person 
who died from puerperal fever. Eroadbent seldom found the 
brain affected in infantile syphilis, and he believes that some 
cases of tubercular meningitis were mistaken for infantile 
syphilis of the brain. 

Hutchinson has observed nervous affections in consequence 
of hereditary syphilis, which manifested themselves by con- 
vulsions with simultaneous kerato-iritis and atrophy of the 
optic nerve in a child eighteen months of age. 

Hughlings Jackson saw a case of facial paralysis and para- 
plegia in a syphilitic child suffering from hereditary syphilis. 

We found in a hereditary syphilitic child numerous gum- 
mata in the brain, and marked thickening of the right facial 
nerve. 

Henoch saw several cases of affection of the testes in con- 
sequence of hereditary syphilis. According to Henning, mor- 
bid alterations may also occur in the treasts of children suf- 
fering from the hereditary disease. 

In consequence of congenital syphilis, morbid alterations 
may occur in the thymus gland, in addition to those originat- 
ing in the permanent organs. Paul Dubois found accumulations 
of pus in the thymus, especially in those infants who suc- 
cumbed to a congenital pustular syphilide. In the year 1858 



SYPHILIS. 333 

Widerhofer dissected a female infant that died from a pustu- 
lar syphilide several hours after birth ; after the removal of 
the sternum the thymus attracted attention by being almost 
double the normal size. Its external surface contained several 
spots about the size of millet-seeds, which, owing to its thin cov- 
ering, permitted the purulent contents of these places to be seen. 
They appeared like small cavities. A longitudinal incision laid 
open a cavity of the size of a hazel-nut, whose apparently 
smooth walls contained a thick, yellowish, purulent fluid. Yel- 
low, syphilitic nodes were imbedded in the substance of the 
liver. Wedl's microscopical examination corroborated the ex- 
istence of a true abscess of the thymus gland. 

Diagnosis and Prognosis of Congenital Syphilis. 

Congenital syphilis in the infant can no more be recog- 
nized by one symptom than it can in the acquired variety in 
the adult. A positive diagnosis can only be made by passing 
in review the whole train of symptoms and studying the en- 
tire pathological picture and all the phenomena present. 

The prognosis of congenital syphilis is extremely unfavor- 
able. More than two thirds of the cases that die from syphilis 
belong to the congenital variety. The morbid lesions origi- 
nating in utero, or shortly after the birth of the infant, ob- 
served by H. Zeissl, almost invariably terminated fatally. Pus- 
tular eruptions, grave cases of coryza, affections of the viscera, 
are the most dangerous symptoms. Infants in whom syphilis 
breaks out at birth, or shortly after, die sooner than those in 
whom the disease appears after the lapse of several days. 
Those who are brought up on artificial food die sooner than 
those who are nursed by a healthy mother or wet-nurse, and 
properly cared for. Congenital syphilis usually puts an end 
speedily to the precarious life of these new-born children by 
lobular pneumonia and exhausting diarrhoeas, accompanied by 
bloody stools and vomiting. Infants, whose life is prolonged 
by judicious treatment, usually remain backward in their de- 
velopment, and retain marked indications of having passed 
through a serious disease, such as the caving in of the bridge 
of the nose, prominent frontal protuberances, opacities of the 
cornea, cicatricial lines radiating from the angles of the eyes, 



334 PATHOLOGY AND TREATMENT OF SYPHILIS. 

mouth, nares, and anus (Hutchinson). Later marked peculiari- 
ties of character develop, and special tendencies to neuroses 
and mental disturbances. 

Syphilis Hereditaria Tarda. 

In rare cases syphilis that is inherited from the parents does 
not appear till many months, indeed, sometimes even many 
years, after birth. This form of inherited syphilis, described 
as hereditaria tarda, appears almost exclusively with the phe- 
nomena of the gummatous period of syphilis, which differ in no 
respect from that of acquired syphilis. As an effect of inherited 
syphilis appearing late in youth, the mucous membrane of the 
cheek, mouth, and fauces, especially, is attacked, and the hard 
palate becomes perforated. Similarly syphilis hereditaria tarda 
seems to have a special predilection for the mucous membrane 
of the nose, and not infrequently terminates in destruction of 
the cartilaginous, indeed, even the bony nasal framework. Gum- 
mata of the skin are comparatively rare, while periostitis, espe- 
cially of the long tubular bones, occurs quite often. The diag- 
nosis can only be established by ascertaining carefully the 
history of the patient, and by excluding acquired syphilis. The 
symptoms mentioned by Hutchinson — the peculiar indenta- 
tion of the permanent incisor teeth of the second dentition 
period — in our opinion, is of no great value. We have never 
seen a case of hereditary syphilis which appeared after the age 
of nineteen years. 

Treatment of Syphilis. 

We will now describe in detail our views regarding the 
treatment of syphilis, which are corroborated by Diday, H. 
Zeissl, and Barensprung. Like any other disease, syphilis 
may get well spontaneously in a long or short time ; and if a 
spontaneous cure takes place, it is likely to be definite. Allow- 
ing syphilis to run its course spontaneously under a carefully 
regulated diet is called the hygienic or expectant method of 
treatment. In addition to the expectant method, there is the 
treatment of syphilis with mercury, iodine, and vegetable reme- 
dies. There is no doubt whatever that mercury will cause the 
symptoms to disappear very rapidly in the majority of cases. 



SYPHILIS. 335 

But it is equally certain that when mercury is employed very 
early — as soon as the primary lesion is detected, or the first 
eruption appears — the symptoms then present will, it is true, 
speedily disappear; but obstinate relapses are more likely to 
follow than when syphilis is first allowed to spend its fury. 
In other words, mercury, if employed in the first few weeks 
of syphilis, will, it is true, soon dissipate the symptoms, but is 
no more able to annihilate the syphilitic diathesis in a short 
time than the expectant or iodine treatment — on the con- 
trary, if used too early, it retards complete recovery. In our 
opinion, mercury should not be used till eight or ten weeks 
after the first eruption has appeared, unless the latter is too 
slow to disappear under expectant or iodine treatment, or dan- 
gerous phenomena threatening some of the organs of sense, 
the viscera, or the central nervous system supervene. We 
coincide in the opinion of H. Zeissl, " that it is not the mer- 
cury that is injurious, but the improper time chosen for em- 
ploying it against syphilis." 

True to the precepts of H. Zeissl's school, our method in the 
treatment of syphilis, briefly stated, is as follows : In patients 
affected with an initial primary lesion, but who are still en- 
tirely free from specific phenomena, such as glandular enlarge- 
ment or eruptions, the treatment is confined to the local lesion. 

If the first syphilitic phenomena appear upon the common 
integument in the form of a macular or papular eruption, we 
prescribe no anti-specific remedies for the patient, even when 
suppurating papules are present in the mouth, on the lips, or 
on the tonsils, but seek to expedite their involution, and to 
render them less painful by prohibiting the use of tobacco 
and cauterizing them with the solid nitrate of silver, or by 
penciling them with a solution of tanno-glycerine (tannic acid, 
5-00 [3iv], to glycerine 20*00 [Jss., 3iv]). If the eruption 
has not entirely disappeared at the end of eight weeks, or if 
no improvement is perceptible, we then prescribe the prepara- 
tions of iodine. 

If the symptoms of the disease have not entirely disap- 
peared after the expiration of eight weeks more, the treatment 
with mercury may be resorted to without any fear concerning 
the future course of the disease. Our favorite remedies are 



336 PATHOLOGY AND TREATMENT OF SYPHILIS. 

Zittman's decoction and the inunction of bine mass. By pur- 
suing the course mentioned, a smaller number of inunctions 
are necessary to cause the symptoms of the disease to disap- 
pear than if a mercurial treatment is instituted from the begin- 
ning. We seldom employ mercury subcutaneously or adminis- 
ter it internally. 

Another important question that presents itself to the 
syphilologist is, whether the treatment of the disease is com- 
pleted when the symptoms that were present at the time the 
patient came under observation have disappeared. This ques- 
tion can only be answered by the statement that the disappear- 
ance of the symptoms is no proof that the diathesis has been 
eradicated ; for otherwise no relapses would follow after a 
longer or shorter interval. We agree, therefore, most decided- 
ly, with the French writers, especially Fournier and Marti- 
neau, that the treatment of syphilis should be continued as 
long as possible. True, it is not necessary that the patient 
be constantly under the eye of the physician ; the subsequent 
treatment may, in fact, be left to himself, it being necessary to 
instruct him to apply for medical- aid again as soon as any 
symptoms recur. 

We think it is very important for the patient, even when 
all the symptoms of the disease have disppeared, to continue 
the treatment with iodine for a long time, at least for a whole 
year. If a patient desires to be treated with mercurial prepara- 
tions, as is now and then the case, a cycle of ten to twelve in- 
unctions may be tried during the first year, albeit no symptoms 
of syphilis manifest themselves. We know, indeed, from 
experiments which Hebra and H. Zeissl instituted, that even 
healthy persons tolerate large numbers of inunctions of mer- 
cury without the least injury. Taking this fact into consid- 
eration, we allow the patients, after the symptoms of syphilis 
have disappeared under the above-described method of treat- 
ment, to resort to the iodine baths at Halle, if their means and 
the season will permit. As soon as they return from the baths, 
iodide of potassium or sodium is again employed, with intervals 
of longer or shorter duration, depending upon the appearance 
of symptoms of iodism. But, if the circumstances are such 
that the patient can not travel to the baths, he should drink 



SYPHILIS. 337 

iodine-water at home for a long time, and then go back to the 
use of one of the preparations of iodine. 

So far we have been perfectly satisfied with the results ob- 
tained by the method of treatment described, the prolonged 
use of the iodides never having proved injurious to the patient. 
But, in view of the statement of Fournier and other authors, 
who assert that grave symptoms of affection of the central 
nervous system ensue in those cases of syphilis that have not 
been treated at all, or only insufficiently, we always prolong 
the treatment as much as possible. We are convinced that 
mercurial preparations play only a subordinate part in a course 
of anti-specific treatment continued for a year or more ; but to 
treat syphilis with mercury for full five years, as some of the 
French physicians do, is hardly justifiable. 

It is not safe to declare a patient permanently cured if at 
least a year has not elapsed after the last symptoms disap- 
peared. 

We will next say a few words regarding the prophylaxis of 
syphilis, and then describe in detail the expectant and other 
methods of treatment. 

Prophylaxis of Syphilis. 

We distinguish general prophylaxis, embracing whole coun- 
tries, and one that has reference to the individual. The for- 
mer belongs to the domain of sanitary police, and the student 
is referred to the literature on that subject. 

Since syphilis has been better known, remedies have been 
sought which would afford protection against the absorption of 
the syphilitic virus, and would make the absorbed virus in- 
nocuous. 

Quacks often pretend that they have many remedies capa- 
ble of accomplishing this purpose ; but none ever proved effect- 
ive. The best protection, comparatively speaking, is derived 
from the use of the condom. 

If a person apprehends that the syphilitic contagium has 
gained an entrance into his system through any point on the 
skin or mucous membrane, the physician can only suggest to 
him to take such measures of protection against the further 
effects of the virus as are employed against the absorption of 

22 



338 PATHOLOGY AND TREATMENT OF SYPHILIS. 

other pernicious matter (glanders, rabies, and soft-chancre vi- 
rus). Strong caustics, such as penetrate deeply into the tis- 
sues, may be used for the purpose of destroying the poison at 
the place of entrance. 

We know, from countless experiments with the virus of 
the soft chancre, that it can be made harmless to the system, 
if the place where it was deposited is thoroughly destroyed 
with caustics within three days. But the time in which the 
syphilitic virus can be rendered innocuous by destroying it 
with caustics has not yet been definitely ascertained by similar 
experiments. It was supposed that, since certain excoriations, 
that originate during intercourse, through which the syphi- 
litic virus may take effect, were effectively cauterized within 
three days, the virus could certainly be destroyed by caustics 
within a few hours after it was absorbed, and thus rendered 
harmless. Unfortunately, most of the patients fail to notice 
the place of entrance of the poison into the system, and do 
not become aware of the fact till the specific primary lesion is 
fully developed, and is undergoing molecular degeneration — a 
process which, as a rule, takes place three weeks after infection 
has occurred, at a period, therefore, when the blood is already 
contaminated. The best agents with which to cauterize the 
place where the virus penetrated is caustic potash and Vienna 
paste. 

Mercurial treatment will not protect one against the origin 
of syphilis, for even persons who are engaged in pursuits where 
a great deal of the mineral is used — for instance, mirror-platers, 
gilders, and others — are not proof against the disease, as has 
been found by experience. 

An English physician (Wilks) propounded the question 
whether syphilis could be aborted. The deliberations of a 
commission resulted in the conclusion that it was totally use- 
less to remove a Hunterian primary indurated lesion, since sec- 
ondary symptoms would nevertheless appear. Sigmund and 
Ricord came to the same conclusions ; the latter says the indu- 
ration is not to be regarded as the cause (origin) of syphilis, 
but as the effect of the constitutional affection. Quite re- 
cently, many physicians have again taken up the subject, and 
stated that they have obtained good results by excising thejpri- 



SYPHILIS. 339 

mary lesion / that is to say, no secondary syphilitic phenom- 
ena ensued. Of the authors referred to, Auspitz and Unna, 
Kolliker, Hueter, Chadzynski, and Ferari are the most promi- 
nent. Auspitz and Unna deserve credit for having lately given 
new impetus to this question. 

But we have convinced ourselves, by a great many experi- 
ments, that extirpation of the indurated primary lesion, how- 
ever early performed after infection, does not prevent the out- 
break of secondary phenomena. Quite recently, H. Zeissl had 
an opportunity of observing a striking instance, in which the 
initial indurated lesion was excised with apparent success, so 
that, according to the statement of the patient, some of the 
most prominent of the French syphilographers, Bassereau, 
Fournier, and Ricord, considered the infecting focus as having 
been completely destroyed, and yet, three months after the 
operation, secondary phenomena appeared in the form of ery- 
thema papulosum on the general skin, although there was no 
possibility that the patient had been reinfected. At the time 
the patient presented himself to H. Zeissl, the erythema was in 
full bloom. The striking case reported by Mauriac is espe- 
cially convincing : A patient contracted a primary lesion which 
was excised fifty hours after it appeared, and, although no in- 
guinal glandular enlargement was present at the time of ex- 
cision, yet general secondary syphilis ensued. This and other 
facts have led us to doubt the effectiveness of the abortive 
treatment of syphilis, and to assert that if there is such a con- 
dition as an incubation period of syphilis, it is of very short 
duration. The excision of the specific primary lesion will 
not prevent the development of constitutional manifestations, 
whether the adjacent lymphatic glands be swollen at the time 
of the operation or not. 

"We will also remark that it is doubtful whether even the 
earliest cauterizations of the infecting initial lesion (Hunte- 
rian induration) are of any use, as a preventive measure against 
constitutional syphilis, because, in the course of an extensive 
practice, we have seen repeated instances in which, according 
to the statements of reliable physicians and patients, the sores 
were cauterized within a few hours after coitus, and yet the 
initial indurated lesion with all its consequences followed. — 



34:0 PATHOLOGY AND TREATMENT OF SYPHILIS. 

The imperative duty devolves upon the physician of exercising 
the utmost caution in procuring the purest vaccine lymph for 
the purpose of vaccinating infants and revaccinating adults, 
and the same precautions should be employed in selecting a 
wet-nurse. Those about to marry, too, might be none the 
worse if they submitted themselves to a careful examination 
by the physician. 

Treatment of the Initial Phenomena of Syphilis ; the Hunterian 
Indurated Chancre; and Indolent, Multiple, and Strumous 
Buboes. 

The treatment of the initial lesions of syphilis is similar to 
that of the other manifestations of the disease. Sometimes, 
however, they require special measures, because they frequently 
cause (local) disturbances and complications that can not be 
relieved speedily enough by the general treatment. 

The site of a syphilitic infecting chancre requires a differ- 
ent local treatment according as it is also the site of a soft 
chancre or not. In the former case, the chancre should be 
treated in the same manner and with the same remedies, re- 
gardless of the induration, as if it were situated upon a non- 
indurated base or non-syphilitic person. In the second case, 
the local treatment is only intended to aid the cicatrization of 
the sore, which is desirable, because the Hunterian chancre, so 
long as it is uncicatrized, causes more or less pain ; and, in case 
it is contaminated with impurities, it is apt to assume a condi- 
tion of phlegmonous inflammation that may spread to the adja- 
cent skin and lymphatic glands of the vicinity. Especially is it 
desirable to cause those Hunterian chancres to cicatrize that 
are situated upon the internal surface of the mucous mem- 
brane of the prepuce, in or near the fossa coronaria, and in 
females at the introitus vaginae, because they frequently give 
rise to protracted balano-blenorrhoea and vulvar blennorrhea ; 
further, those on the lips, at the anus, and meatus of the 
urethra, because they occasion pain in speaking, defecation, 
and urination. The cicatrization of the initial induration is 
expedited by keeping it clean, by the application of iodoform 
dressing, or emplastrum hydrargyri. If the Hunterian chancre 
on the mucous membrane of the prepuce has occasioned phi- 



SYPHILIS. 341 

mosis, some tolerably strong astringent, or slightly caustic 
preparation, such as a solution of carbolic acid or chlorate of 
potash, should be injected between the foreskin and glans 
penis several times daily. After this, bits of muslin, dipped 
in the same preparation, should be inserted under the former 
for the purpose of keeping the inflamed parts asunder. If 
this does not answer, circumcision will be required. If the 
Hunterian chancre is situated at the lips of the urethral mea- 
tus, it should be touched daily with nitrate of silver, and a 
small wedge of emplastrum hydrargyri inserted between the 
lips. The same method should be pursued in chancres at the 
anus or vulva. Hunterian indurated lesions situated on the 
skin of the penis, labia majora, or fingers, cicatrize quickest 
when they are covered with adhesive or mercurial plaster. 

Indolent buboes of the size of a hazel-nut require no local 
treatment. The treatment directed against the general disease 
usually suffices to reduce them in size or to bring about reso- 
lution. If the indolent bubo accompanying the syphilitic initial 
lesion undergoes suppuration, it should be treated, cceteris pari- 
bus, like any other suppurating glandular abscess ; but if the 
syphilitic, indolent buboes, fostered by the scrofulous or tuber- 
culous tendency of the patient, or by ulcerating or moist pap- 
ules in the vicinity, gradually increase, notwithstanding the 
general treatment already instituted, an effort should be made 
by appropriate local treatment to prevent suppuration, because 
of the fistulous passages that usually result from inflammation 
of the hyperplastic enlarged glands (strumous buboes). The 
reader is referred to what has already been said upon this sub- 
ject on page 141. In some cases we succeeded in gradually 
diminishing these adenopathies by several subcutaneous injec- 
tions of a few drops of tincture of iodine. A concentrated 
solution of nitrate of silver, or compresses dipped in a concen- 
trated solution of basic acetate of lead, or iodide of lead-plaster, 
tincture of iodine, belladonna, or gallic acid, will be found 
useful. The following is one of the best preparations : 

^ Aqua destil., 20*00 [ § ss., 3 iv] ; 
Nitr. arg. cryst., 5-00 [3 iv]. 
M. S. The glandular swelling to be penciled twice daily with a cam- 
el's-hair brush. 



342 PATHOLOGY AND TREATMENT OF SYPHILIS. 

Emplastrum de Vigo curia hydrargyri will usually cause a 
diminution of strumous buboes. 

If the strumous bubo, per se, does not prevent the patient 
from walking, it is not absolutely necessary that he should re- 
main in bed ; indeed, a moderate amount of exercise out-of- 
doors seems to hasten resolution. 

If fluctuation has been detected at any place, the efforts to 
bring about absorption should not yet be abandoned, nor the 
abscess opened immediately, because experience has shown that 
even indolent buboes that fluctuated distinctly were neverthe- 
less made to undergo resolution by the continuous application of 
tincture of iodine, lead-plaster, etc. Not till a prolonged trial 
of the above-mentioned remedies causes no diminution of the 
swelling, on the contrary, seems to increase it, make it more 
tense, and give the patient severe pain, may the spontaneous 
bursting of the abscess be expedited by the application of cata- 
plasms, etc. ; or it may be incised with a sharp-pointed bis- 
toury. The part of the skin that has become thin, red, and 
undermined may be removed at once with the scissors. The 
opened indolent bubo should then be treated in accordance 
with the rules of antiseptic surgery. If fistulse form, the 
measures advocated on page 14:2 may be adopted. 

Treatment of Secondary Phenomena of Syphilis. 

(A.) Expectant Method. 

The expectant plan of treatment consists in regulating the 
diet of the patient, and in the local application of remedies to 
the primary lesion, none being administered against the general 
specific disease. If the primary lesion has begun to suppurate, 
the patient should be prohibited from taking active exercise, 
in order to avoid the risk of causing suppuration in the in- 
guinal glands ; if it has cicatrized, or did not suppurate at all, 
the patient should be in the open air as much as possible. He 
should avoid catching cold, abstain from the use of tobacco, 
and partake of nutritious food, especially meat. He may be 
allowed a moderate amount of wine and beer, but tobacco 
should be prohibited absolutely, because the irritation pro- 
duced by its use will occasion the formation of syphilitic 



SYPHILIS. 343 

efflorescences on the mucous membrane of the mouth, tongue, 
and fauces. It is highly important for the patient to wash the 
anal region with water after each stool. In corpulent persons 
contiguous parts should be kept asunder by the interposition 
of bits of lint. The constant contact of two opposing sur- 
faces, as at the anus, groin, etc., always produces considerable 
moisture, and this results in the development of papules. 

If secondary phenomena, in the form of a macular or papu- 
lar syphilide, have finally appeared, the physician should still 
content himself with carrying out these hygienic measures. 
Syphilitic phenomena last a variable length of time in differ- 
ent persons. Roseola undergoes resolution without medication 
quite rapidly. In one case we saw it disappear within seven 
days. Papular syphilides often require a loug time to under- 
go involution. Psoriasis palmaris and plantaris frequently re- 
quire, if not treated, ten to twelve months before they dis- 
appear by resolution. An equal length of time often elapses 
before the syphilitic initial induration completely subsides. 
But it should not be forgotten that similar conditions are 
often seen in persons who undergo active mercurial treatment. 
We have observed that the individuality exercises considerable 
infiuence over the rapidity with which the syphilitic symptoms 
disappear. In general, it may be said that the cure of syphilis 
in anaemic and weak persons takes a longer time and is more 
difficult than in the robust and well - nourished. In regard 
to pustular syphilides, these, too, often require, under ex- 
pectant treatment, seven to eight months to disappear by 
resolution. 

The expectant treatment has taught us, on the one hand, 
that constitutional syphilis will follow even if not a particle of 
mercury is used, and, on the other hand, that the assertion of 
the anti-mercurialists, that the so-called secondary and tertiary 
syphilis are only the manifestations of the mercurializatidn, is 
not true. Relapses and the gravest forms of syphilis (symp- 
toms denoting lesions of the central nervous system, of the 
viscera, etc.) may supervene just as well after a strict and scru- 
pulously carried out expectant plan as after an anti-specific 
treatment. We only wish to say that these phenomena occur 
comparatively rarely after expectant treatment, and that re- 



344 PATHOLOGY AND TREATMENT OF SYPHILIS. 

lapses are apt to occur less often than after an early mercurial 
treatment. If serious syphilitic symptoms have appeared, such 
as affections of the brain or eye, the anti-specific remedies 
should be employed at once, and the life of the patient or the 
integrity of an important organ should not be endangered by 
delay. 

All recent cases of acquired secondary syphilis are well 
adapted for treatment by the expectant method. If a febrile 
disease — pneumonia, dysentery, typhoid fever, etc. — super- 
venes upon the specific phenomena, mercury, iodine, and all 
depressing remedies must be discontinued, and the syphilitic 
disease treated with expectants for the time. In very severe 
forms of pustular syphilide similar indications prevail. Little 
can be hoped for from the expectant method in cases in which, 
after a long or short use of specific remedies, especially mer- 
cury, a relapse ensues. Cases of congenital syphilis which ap- 
pear in youth, and are likely to cause destruction of some of 
the soft or bony parts (lupus syphilitica), are not adapted for 
the expectant method of treatment. 

If the phenomena of the second period have resisted this 
method for eight or ten weeks, the treatment with iodine may 
be commenced. The treatment with preparations of iodine is 
adapted to all phases of syphilis, and, according to H. Zeissl's 
experience, the results derived from it are second to those of 
the expectant procedure, since relapses occur less often after 
an early treatment with iodine than with mercury. 

Iodine in proper quantities, in conjunction with a carefully 
regulated regimen, are sufficient to cause the symptoms of 
syphilis to disappear, or at least to oe weakened so that only 
a few mercurial inunctions will he necessary to complete the 
cure, without fear of a relapse occurring in years to come. 

In pregnant women the symptoms of syphilis resist treat- 
ment much more than in non-pregnant women, especially if 
pregnancy is as old as the infection ; they do not disappear en- 
tirely till the contents of the uterus have been expelled. "We 
were, therefore, always obliged to continue the treatment with 
the preparations of iodine after the confinement, and, where 
this remedy proved insufficient, a few inunctions of mercury 
completed it. 



SYPHILIS. 345 

Therapeutical Application of Iodine and Iodine-Salts against 

Syphilis. 

(B.) Medicinal Treatment. 

Since 1822 iodine has been used with good results in syphi- 
lis by Formey, Brera, Lugol, Cullerier, and Eicord; but it 
became famous as an antisyphilitic remedy mainly through 
the writings of Professor Wallace, of Dublin, who, in the year 
1836, published a report of one hundred and forty-two cases 
treated with iodide of potassium, in which he obtained most fa- 
vorable results. 

We employ mainly iodide of potassium, iodide of sodium, 
iodide of iron, iodoform, and iodide of lithium. Pure iodine, 
which, owing to its corrosive action, is not adapted for internal 
use, may be given in the form of tincture. Of the latter we 
prescribe 1-00 [grs. xvj] to 100*00 [ § iij, 3 iij] water, and allow 
the patient to take two teaspoonfuls a day. Of iodide of potas- 
sium or sodium we order 1*00 [grs. xvj] either in solution or 
pill. The latter is preferable, because the bad taste of the 
medicine is thus avoided. En passant, we will state that iodide 
of sodium is less disagreeable than iodide of potassium. We 
use iodide of iron, either in the form of pills or sirup, as 
follows : 

5 Ferri ioclat., 10*00 [3 viij] ; 

Extract, et pulvis trifolii fibrini aa 

q. s. ut ft. pilulae No. 100. 
Consperge pulvere eodem. 
S. Ten pills, to be taken daily. 

¥? Syr. ferri iodat., 2*00 [grs. xxxij] ; 
Syr. mororum, 20*00 [ § ss., 3 iv], 
M. S. To be taken in one day. 

Iodide of iron is especially adapted for the treatment of 
syphilitic patients who are markedly angemic. A gramme 
[grs. xvj] of iodide of iron daily, in pills, is very well tolerated ; 
we have often given as much as 2*50 [grs. xl] without causing 
any digestive disturbances. In very weak patients, whose di- 
gestive organs are not strong, the sirup of the iodide of iron 
may be prescribed, but only in quantities necessary for each 
day, as it easily decomposes, and the free iodine then produces 



346 PATHOLOGY AND TREATMENT OF SYPHILIS. 

pain in the stomach and vomiting. The decomposition of the 
iodide of iron is prevented in Blancard's pills, which are 
wrapped up in balsam of Torn. Each pill contains 0*07 [1-J- 
gr.], of which the patient takes four or fi.ye each day. Much 
benefit is derived from the internal use of iodoform, according 
to H. Zeissl's method. It is prescribed in pill-form : 

3 Iodoform., 1'50 [grs. xxiij] ; 

Ext. et pulv. trifolii fibrini aa ut ft. pil. No. 20. 

Consperge pulvere eodem. 
S. Five pills to be taken daily. 

Good results are obtained from iodoform, especially in 
cases of neuralgia caused by syphilis. In addition, we only 
wish to mention here that patients, after the internal use of 
iodoform, sometimes suffer for a long time from unpleasant 
eructations. It should not be prescribed in large doses ; some 
physicians have seen intense excitement and mental disturb- 
ances arise in patients to whom large quantities of the drug 
were administered. . 

Iodide of lithium, which till now has not been much noticed, 
may be given in doses similar to those of iodoform. We have 
used it for several months, injecting it subcutaneously. It 
forms a perfectly clear solution when dissolved in water ; 1*50 
[grs. xxiij] may be injected hypodermically. The patients 
complain of pain at the site of injection, but it soon subsides. 
In this manner the preparation is very well tolerated, pro- 
ducing no other unpleasant effects except a moderate iodine 
acne in some cases. The involution of the syphilitic phe- 
nomena proceeded as rapidly as after the use of any other 
preparation of iodine. Iodide of lithium may also be adminis- 
tered internally in pills from 0*50 [grs. viij] to l'OO [grs. xvj] 
per day. This preparation accomplishes as few miraculous cures 
as any other. Recently Thomann, of Gratz, and J. Neumann, 
injected iodoform in solution or emulsion hypodermically with 
good effect. As already said, all phases of syphilis are adapted 
for treatment with the preparations of iodine. We have seen 
numerous cases of iritis cured by the administration of iodine 
and application of atropine to the eye, not the least impairment 
of vision remaining in a single patient. 



SYPHILIS. 347 

The rule that mercury causes the symptoms of syphilis in 
all cases to disappear more rapidly than any other anti-specific 
remedy, has but a limited application ; in some cases both mer- 
cury and iodine act quickly, in others their effects upon the 
patient are very slow. Too much stress can not be laid upon 
the fact that even in the gravest forms of syphilis the prepa- 
rations of iodine alone will often be found sufiicient. 

In regard to the subcutaneous employment of the prepa- 
rations of iodine, it may be used with advantage in persons 
troubled with weak digestive organs ; but this method will no 
more take the place of the internal use of the drug than the 
hypodermic injection of mercury has till now succeeded in re- 
placing mercurial inunction. However slight the pains may 
be, the patients seek to avoid them if not absolutely necessary. 
Besides, it has the additional diad vantage that in private prac- 
tice a syphilitic patient can not be seen every day. 

Patients, whose health and other circumstances permit, 
should go at the proper season of the year to iodine min- 
eral springs. There are several places in the Austro-Hunga- 
rian Empire where valuable iodine springs are found, such as 
Hall in Upper Austria, Ivonicz in Galicia, Lippik in Slavonia, 
Luhatschowitz in Mahren, and Darkau in Silesia. In these 
places the patients not only drink iodine- water, but also bathe 
in it. Professor Rosenthal, of Vienna, under the direction of 
Professor Schneider, has shown, in a paper presented to the 
Imperial Academy of Sciences in the year 1862, that iodine is 
absorbed into the blood by the skin. 

It is a mistaken idea to prohibit the patient from partaking 
of articles of food containing starch during the treatment with 
iodine. Starch alone, without the simultaneous intervention 
of an acid, is not capable of separating the iodine from its 
compounds and forming a combination with it. The acids of 
the stomach are much too feeble for that purpose ; and admit- 
ting that a partial decomposition of the iodides takes place 
from an excess of starch in the stomach, then only an iodide 
of starch would form, which is the very substance recom- 
mended by Buchanan against syphilis on account of its non- 
irritating action on the gastric mucous membrane. Equally 
little injury results to the patient, according to our experience, 



34:8 PATHOLOGY AND TREATMENT OF SYPHILIS. 

from the decomposition of the preparations of iodine, owing 
to the nse of acids during the treatment with iodides. Be- 
cently, English physicians have actually sought to increase the 
action of this remedy, aud obtained favorable results from the 
combined use of tolerably strong acids (ozonized water, nitric 
acid) with preparations of iodine. The powerful action of the 
salts of iodine, in bringing about a metamorphosis of the tis- 
sues, is reason enough for allowing the patient, during the 
iodine-cure, to partake of as much nourishing diet, especially 
animal food, as possible, still the cure should not be made un- 
necessarily irksome by prohibiting the ingestion of bread. 

The preparations of iodine, as already stated above, are 
adapted to all forms of syphilitic disease. 

The iodides have proved especially efficacious against gum- 
mous periostitis and ostitis, gummata of the skin, tongue, 
respiratory organs, etc. ; in muscular contractions, sarcocele 
syphilitica, specific eye, brain, and nervous affections, inherited 
syphilis, appearing in the shape of scrofulous manifestations, 
and in cases in which scrofula and syphilis are combined. 

Still, there are cases in which all the morbid forms men- 
tioned obstinately resist the action of the iodine remedies ; in 
such, if the condition of the patient permits, we resort to the 
mildest of all mercurial preparations, Zittmann's decoction. 
The mercurials generally achieve more if they have been pre- 
ceded by a course of treatment with iodine. 

It follows, from what has been said, that the salts of iodine 
are the chief remedies for so-called tertiary syphilis. Still, it 
can not be denied that all the other specific phenomena may 
be made to undergo involution by the use of iodine ; but it is 
equally true that there are exceptional cases, which can not be 
foretold, in which mercury may be advantageously substituted 
for the iodide. 

When iodine preparations are used in appropriate cases and 
in proper doses, the appetite of the patient increases, and nutri- 
tion improves proportionally. Sometimes, however, the appe- 
tite increases to a ravenous hunger. Occasionally the internal 
use of the iodides causes ringing in the ears and intestinal 
catarrh, which sometimes is attended by loose stools, then again 
by constipation. The pathogenic action of iodine manifests 



SYPHILIS. 349 

itself most strikingly upon the nasal mucous membrane, a 
violent nasal catarrh originating in most patients after this rem- 
edy has been used .for two or three days. This phenomenon 
is generally accompanied by an irritated condition of the mu- 
cous membrane of the fauces and pain over the frontal sinus. 
The catarrhal affection of the mucous membranes mentioned 
extends to the lachrymal apparatus and Eustachian tube. 
More or less severe febrile movement, according to the sensi- 
tiveness of the patient, ensues. In most cases we noticed, in 
consequence of the continuous use of the iodides, marked red- 
ness and looseness of the gums of the upper incisor teeth 
(gingivitis), which persisted for many weeks, along with ob- 
stinate salivation. The pathogenic action of iodine salts mani- 
fests itself just as frequently upon the general skin as upon the 
naso-faucial mucous membrane. An acne-like eruption occurs 
in some persons, especially those having a tender skin, on the 
face, nape, shoulders, and upper arms. The iodine catarrh 
and acne may indeed occur simultaneously, but, as a rule, these 
two affections exclude each other. In some patients the use 
of the salts of iodine produces sleeplessness. In rare cases we 
have observed, in consequence of the internal use of the prepa- 
rations under consideration, episcleral ecchymoses and ncevus- 
UJce teleangiectases, as big as a pin's head, on the general integu- 
ment. In some cases the action of the heart is accelerated to 
such a degree, by a prolonged use of this remedy, that the 
rapidity of the pulse is increased to one hundred and forty per 
minute, the patient being at the same time exceedingly irri- 
table and exhausted. We also saw pleurodynia occasionally 
in consequence of the use of iodine — a phenomenon first point- 
ed out by Wallace. The pain, which is usually limited to the 
left side of the thorax, is so violent at times as to hinder the 
patients from breathing, resembling very much in severity 
that occurring in true pleurisy. 

Iodine catarrh and iodine acne disappear when the iodides 
are discontinued. For the relief of the gingivitis, the astrin- 
gent mouth-washes recommended against mercurial stomatitis 
may be used. The ravenous hunger and sleeplessness, the 
pleurodynia, and increased action of the heart are markedly 
diminished by an active purgative (Saidschiitzer or Pullnaer 



350 PATHOLOGY AND TREATMENT OF SYPHILIS. 

bitter-water), and disappear entirely after the use of a few 
doses of quinine, 0*3 to 0*4 [grs. v to vij] daily. 

The Treatment of Syphilis by Vegetable Remedies. 

Of the vegetable remedies, we will only mention tayuya, pi- 
locarpine, and Zittmann's decoction. Tayuya-tincture has been 
recommended by the Ubicini brothers. It is prepared from the 
root or bulb of one of the cucurbitacea plants. This remedy 
was used in the form of subcutaneous injection, and also inter- 
nally in H. Zeissl's hospital division. The results were such 
that it may be said that time and not the remedy accomplished 
the cure. However, it exercises no injurious effect upon the 
system. Lewin made numerous experiments with jpiloca/rpin, 
the alkaloid of jaborandi. He used the muriate, and treated 
thirty-two women with it by hypodermic injections ; twenty- 
five of the patients were cured. In three of the seven that 
were not cured, such violent symptoms of collapse appeared 
that the treatment had to be discontinued. One patient was 
attacked by haemoptysis — in another endocarditis supervened. 
In two others the syphilitic manifestations did not disappear, 
notwithstanding the large doses of pilocarpine employed. 
The longest time required for a cure was forty-three days, 
the shortest fourteen. Lewin thinks that a cure could be 
achieved in a still shorter time, if it were not necessary to sus- 
pend the treatment, even when no accidents occurred, on ac- 
count of the patients' being frequently very much affected by 
it. The average quantity of pilocarpine required for a cure is 
0-372 [grs,vss.]. 

The relation of pilocarpine to the different forms of syphi- 
lis is pretty much the same as that of mercury. The relapses 
in these twenty-seven patients amounted to only six per cent, 
against eighty per cent after a vegetable cure or previous treat- 
ment with mercury. Nevertheless, Lewin gives the preference 
to hypodermic injections of corrosive sublimate over the treat- 
ment with pilocarpine, for, although the percentage of cures 
with the latter is decidedly greater, yet the use of the remedy 
is attended by such unpleasant symptoms. In some cases in 
which we employed hypodermic injections of pilocarpine the 
unpleasant effects were so violent that we had to abandon all 



SYPHILIS. 351 

further treatment with it, especially since the curative effects 
were by no means satisfactory. 

But from Zittmann's decoction we have seen very brilliant 
results. It is difficult to say whether this remedy should be 
classed among the vegetable or the mercurial preparations. 
In preparing this decoction, as is well known, 1*00 [grs. xvj] 
of white sugar, a like quantity of powdered alum, 0*8 [grs. 
xij] powdered calomel, and 0*2 [grs. iij] powdered cinnabar, 
are boiled in a little bag with sarsaparilla. Mitscherlich was 
unable to detect any mercury in the decoction, while Zanten, 
Wiggers, and Winkler found traces of it in large quantities of 
the preparation. Skoda found Zittmann's decoction less effica- 
cious when calomel and cinnabar were omitted. For these 
reasons, we have to assign to Zittmann's decoction a hybrid 
position between the vegetable and purely mercurial remedies. 
We order the patient to take 30O00 [ § ixss., 3iv] of decoct. 
Zittmanni fortius every morning, and the same quantity of the 
weaker decoction in the evening. At the same time the diet 
must be strictly regulated. He should drink no liquor, beer, 
or milk. Fruits, salads, all kinds of vegetables and fruits — in 
a word, everything that is likely to cause diarrhoea and flatus — 
must be strictly prohibited. At 7.30 a. m., the patient takes 
his breakfast, consisting of a cup of black tea and toast. 
Half an hour after, he begins to drink the decoction, which he 
finishes in the course of half an hour to two hours. Generally, 
from one to three evacuations from the bowels then occur in 
the course of the forenoon. At one o'clock he takes his din- 
ner, consisting of soup, roast beef, and rice, with a glass of 
wine, and, if the weather is pleasant, he may take some exer- 
cise out-of-doors, and, at 4 p. m., drinks a second bottle of the 
(weaker) decoction, likewise consuming it in the course of half 
an hour to two hours. 

If the patient has five or six evacuations daily, he may con- 
tinue to take the decoction ; but if they become too frequent, 
and perceptibly reduce him, or vomiting ensues, the remedy 
must be immediately discontinued. In the majority of cases, 
not more than three or four evacuations take place daily, the 
decoction agreeing very well with most patients. The effects 
of the remedy usually become manifest after using it ten or 



352 PATHOLOGY AND TREATMENT OF SYPHILIS. 

twelve clays ; it has an exceedingly favorable effect upon all 
forms of syphilis, but is especially applicable in patients who 
are somewhat exhausted by a severe course of mercury, and in 
whom the syphilitic disease obstinately resists the preparations 
of iodine. It is an indisputable fact that, in patients who had 
been treated early and for a long time with mercury, obstinate 
relapses of the syphilitic disease, in the form of psoriasis pal- 
maris or plantaris, will not disappear at all, or but very slowly, 
under the use of the iodides, the malady improving only when 
mercury is again administered. But, if it be not deemed proper 
to give such patients more mercury, because they are already 
reduced by the preceding active treatment with it, Zittmann's 
decoction may be prescribed. Truly wonderful effects may be 
expected from it, though such an expression ought not to be 
used in the practice of medicine at the present day. It ren- 
ders excellent service in diffused pustular syphilides, and in 
suppurating gumma-nodes, whether situated upon the common 
integument cr the mucous membrane. If the decoction occa- 
sions violent colic-pains or profuse diarrhoea, and its further 
employment is indicated notwithstanding, it will be well to 
omit the senna-leaves from the preparation. 

[The formula given above for the preparation of Zittmann's 
decoction being incomplete, that described in the United States 
Dispensatory is here appended : Take of sarsaparilla twelve 
ounces, spring-water ninety pounds ; digest for twenty-four 
hours, then introduce, inclosed in a small bag, an ounce and a 
half of sugar of alum (consisting of equal parts of white sugar 
and powdered alum), half an ounce of calomel, and a drachm of 
cinnabar. Boil to thirty pounds, and, near the end of the boil- 
ing, add of anise-seed, fennel-seed, each half an ounce, senna 
three ounces, liquorice-root an ounce and a half. Put aside the 
liquor under the name of the strong decoction. To the residue 
add six ounces of sarsaparilla and ninety pounds of water. Boil 
to thirty pounds, and, near the end, add lemon-peel, cinnamon, 
cardamom, liquorice, of each three drachms. Strain, and set 
aside the liquor, under the name of the weak decoction.'] 

Therapeutic Use of Mercury. 
Mercury may be introduced into the system in two ways — 
through the mucous membrane of the digestive and respiratory 



SYPHILIS. 353 

organs, and through the general skin. Now, if in the patient 
who is about to be treated, one of these ways become unavail- 
able, in consequence of syphilis itself, or because of some 
morbid alterations or complications, it will be necessary to find 
some other course whereby the mercury may be introduced 
into the system. Further, if it is the intention of the physi- 
cian to produce a mild and gradual therapeutic effect, and if 
the digestive organs of the patient are in a good condition, 
the latter may be employed. But if he desires to introduce a 
large quantity of mercury into the system in a short time, the 
external skin is certainly best adapted for that purpose. If it 
is desired to produce a direct specific effect upon the respira- 
tory organs, mercury may be inhaled in the form of vapor. 

Mercurial Preparations which are best adapted for Introduction 
into the Blood through the Digestive Organs. 

Although we entirely agree with Mialhe in his theory that 
all preparations of mercury introduced into the system must, 
before developing their therapeutic effects, become converted 
into corrosive sublimate, and hence that it would seem to be 
more advantageous to use the bichloride at once, nevertheless, 
we must say that the other preparations of mercury, are by no 
means to be discarded. Experience has shown that some per- 
sons are apt to suffer from gastric pain after taking corrosive 
sublimate, while the protoiodide of mercury or calomel agrees 
with them very well indeed. It therefore seems as if some 
persons tolerate better the sublimate that forms within their 
systems from the protoiodide or calomel than when it is ad- 
ministered to them directly. 

Most German physicians at present prefer corrosive subli- 
mate to any other preparation of mercury, because it so seldom 
produces ptyalism, while this unpleasant by-effect almost always 
attends the use of the protoiodide, calomel, and mercurius solu- 
bilis Hahnemanni. The salivation which sometimes supervenes 
very rapidly upon the use of mercurial preparations seems to 
us to be due more to individual idiosyncrasy than to the 
chemical properties of the drug ; hence the reason why some 
of the most accomplished physicians differ so much upon this 
point. 



354 PATHOLOGY AND TREATMENT OF SYPHILIS. 

Hydrargyri protoioduretum, iodide of mercury, a greenish 
insoluble combination of iodine with mercury, is especially 
recommended by Kicord, and adapted in cases in which the pri- 
mary induration still exists, in recent erythematous and papu- 
lar syphilides, and in psoriasis palmaris and plantaris dissemi- 
nata. As a rule, the involution of the specific efflorescences 
on the skin and mucous membrane begins after using the 
protoiodide for two or three weeks. The papules on the 
palms of the hands and soles of the feet offer the most obsti- 
nate resistance to the action of the remedy, and local applica- 
tions will almost always be required to assist the protoiodide 
in discussing them. 

The dose of the protoiodide is 0*02 to 0*04 [gr. i to §]. 
Generally, patients who take 0*10 [gr. If] of this remedy in 
twenty-four hours have two or three liquid evacuations, at- 
tended by colic-pains. To prevent the latter, the mercurial 
should be combined with extract of lactucaria or opium in the 
following manner : 

B Protoiod. hydrargyri: 

Extr. lactucarii, aa 1*00 [grs. xvj] ; 
Opii puri, O50 [grs. viij] ; 

Extr. et pulv. rad. liquiritia, aa q. s. ut ft. pil. No. 50. 
S. One pill to be taken in the morning and two in the evening. ' 

So long as the protoiodide exercises a perceptibly favorable 
effect over the induration or the other syphilitic manifestations 
present, and the mucous membrane of the mouth remains un- 
affected, the dose recommended above may be continued. But, 
if the improvement of the syphilitic lesion is arrested, two 
pills should be given in the morning and two in the evening. 
Should the patient's gums become red and swollen, and his 
breath acquire a repulsive odor, the remedy will have to be 
discontinued till the mucous membrane regains its normal 
condition. If the protoiodide, despite the addition of the nar- 
cotic, causes intense colic-pains; if profuse, liquid, or, still 
worse, bloody stools take place, the internal use of all kinds of 
mercury should be suspended, and the patient subjected to an 
inunction-cure, or the iodides may be prescribed. 

Chloride of mercury, being soluble, is a more useful rem- 
edy than the protoiodide ; still, it can only be used internally in 



SYPHILIS. 355 

persons who have perfectly healthy digestive organs and sound 
respiratory apparatus. There are patients in whom the use of 
corrosive sublimate occasions gastralgia, and for that reason 
the remedy must be replaced by one that is less useful. In 
persons who have already suffered from attacks of hemopty- 
sis, mercury in general, but especially corrosive sublimate, 
should be used cautiously. If albuminuria is present, large 
doses of the bichloride act equally unfavorably. No corrosive 
sublimate, and, still less, other drastic mercurial preparations, 
should be prescribed for syphilitic pregnant women. The 
treatment of syphilis with corrosive sublimate was introduced 
into Western Europe by Yan Swieten, from Russia. The Rus- 
sians take this medicine in corn-whisky (liquor Yan Swietenii). 
Adult patients readily tolerate a dose of the sublimate of 
0-005 to 0*02 [gr. ^ to -§-] per day. As a rule, it is best to 
continue to the end of the sublimate cure with a dose of say 
0*010 [gr. £] per day. But if the syphilitic phenomena re- 
main at a standstill for several days, and there are no contra- 
indications in the constitution of the patient against larger 
doses of mercury, it may be increased gradually at the end of 
three or four weeks to 0*012 or 0*015 [gr. \ to £]. It is better 
to administer it in the form of pills than dissolved in water 
or alcohol. The following is the most convenient method : 

5 Mur. hydrarg. cor., 0*10 [gr. 1£] ; 
Solve in pauxillo aether snlph., et adde 
Pulv. aniyli q. s. ut ft. pil. No. 20. 
D. S. One pill to be taken morning and evening. 

IJ Mur. hydrarg. cor., 0*10 [gr. H] ; 
Aqua destil., 300-00 [ § ixss., 3 iv]. 
M. S. One tablespoonful to be taken morning and evening. 

For the purpose of preventing the gastralgia and the colic- 
pains, the patient should avoid taking the medicine, especially 
his morning dose, on an empty stomach ; a bowl of broth or 
milk should always precede it by about half an hour. If the 
patient is in the habit of drinking tea, morning and evening, 
then the following may be prescribed : 

B Rhum. optimi, 20*00 [ I ss., 3 iv] ; 
Sublimat. cor., 0-10 [gr. 1J], 
M. D. S. Twenty drops to be taken in the tea, morning and evening. 



356 PATHOLOGY AND TREATMENT OF SYPHILIS. 

We seldom prescribe calomel or submuriate of mercury ; in 
fact, only in such cases in which we desire to administer large 
doses of mercury through the digestive system in a short time. 
In dangerous iritis especially, and in specific affections of the 
fauces, calomel has proved to be one of the quickest remedies to 
produce good effects. In adults it may be given in the follow- 
ing form : 

3 Calomel laevigati, 0*50 [grs. viij] ; 

Opii puri, 0*10 [gr. lfj. 

Sacchar. alba, 5-00 [3 iv]. 
M. Div. in dosis No. 12. 
D. S. One powder to be taken morning, noon, and night. 

On the whole, we have used very little sublimate or sub- 
muriate of mercury for many years past, because we have con- 
vinced ourselves that no other preparations will produce such 
peculiar and obstinate alterations of the epithelial cells of the 
mucous membrane of the mouth and tongue as these, especially 
if the patient is addicted to the use of tobacco. In these pa- 
tients there are found most frequently on the mucous mem- 
brane of the tongue, lips, and cheeks, especially on the places 
that come in contact with the angles of the teeth, pearly- white, 
opalescent opacities of the epithelial cells, varying in size from 
that of a pin's head to that of a bean, which may be either 
scattered or aggregated. These places look as if they had been 
touched with nitrate of silver. They are distinguished from 
mucous-membrane papules by the absence of diphtheritic 
slough upon them ; they do not ulcerate, display no local pro- 
liferation of the papilla, often terminate in retractions of the 
affected places of the mucous membrane, because, in conse- 
quence of the pressure of the epithelial thickening upon the 
affected papillae, the latter retract, while the epithelial opacity 
is so persistent that it remains unaltered for many years. In 
accordance with an article published by Wiensky, a Eussian 
physician, who on injecting cinnabar into the blood of animals 
found it again encysted in the epithelial cells, H. Zeissl feels 
justified in asserting that the opacities spoken of are nothing 
more than epithelial cells containing mercury. In proof of 
this view, we can say that we never saw these persistent opaci- 
ties in persons who were not treated with corrosive sublimate. 



SYPHILIS. 357 

As an additional proof, we may point to an analogous alteration 
of the epithelial cells seen in the blue color on the gums ot 
persons who handle lead, and in the bronzing of the skin and 
buccal mucous membrane produced by the internal administra- 
tion of nitrate of silver. As the internal employment of mer- 
cury is generally adopted in the treatment of recent manifesta- 
tions of syphilis, that is to say, at a time when the indurated 
infecting places are still suppurating and the indolent buboes 
are still progressing, it will be well for the patient to avoid all 
active exercise, though it is not necessary that he should stay 
in bed. Furthermore, as the patient frequently suffers from 
rheumatoid pains at the beginning of syphilis, he should not 
expose himself unnecessarily to sudden changes of temperature, 
and especially should he protect himself against cold and damp 
night-air. It is even beneficial for him to sweat some at night. 
Under moderate diaphoresis, the disease not only runs a fa- 
vorable course, but the internal use of mercury is better tol- 
erated. For this reason, most physicians order the patient 
to take a larger dose of mercury on going to bed than at other 
times. 

In regard to the diet, the patient may be allowed to take a 
moderate amount of nourishment ; it is only necessary for him 
to avoid all kinds of vegetables and fruit that cause flatus, and 
all articles that contain vegetable acids, lemonades, etc., which 
are incompatible with the remedies, and readily give rise to 
nausea, colic-pains, and diarrhoea. If calomel is used internally, 
the patient should not be allowed to partake of very salty food, 
such as salt herring, or drinks containing soda ; nor of am- 
monia, because the composition of the calomel is thereby liable 
to be changed, and, it is claimed by some physicians, that 
sudden deaths have resulted from it. He should i enounce 
the use of tobacco in every shape absolutely during the treat- 
ment with mercury, especially when the sublimate is used. 
How long a time is required to accomplish a cure with mer- 
cury, and how much of the different preparations is necessary 
to completely annihilate syphilis, depends upon the individual 
case. As a rule, the mercurials should be administered to the 
patient, if he tolerates them, till all the symptoms have disap- 
peared, which will seldom occur in less than two or three 



358 PATHOLOGY AND TREATMENT OF SYPHILIS, 



months. Accordingly, a patient will consume about 4*00 
[grs. lxij] of the protoiodide, or 0*5 to 1*00 [grs. viij to xvj] 
of corrosive sublimate. The treatment must be suspended, 
at least for a time, as soon as the mucous membrane of the 
mouth is affected, and the patient should rinse his mouth with 
some astringent preparation every half -hour. 

External Application of Mercury and its Preparations. 

The absorption of mercury into the blood through the skin 
can be accomplished in the following manner : 

(a) By repeated inunctions of salve, containing mercury, 
over a large portion of the skin (epidermatic mercurial treat- 
ment). 

(b) By injections into the subcutaneous tissue (hypodermic 
mercurial treatment). 

(c) By the action of vapor of mercury through the skin. 

(d) By the use of mercurial baths. And, lastly — 

(e) By the local use of mercury in the form of suppositories 
upon the mucous membrane of the rectum. 

(a) Mercurial Inunction Treatment. 

The method of treating syphilis by means of mercurial 
ointment came into vogue at the very beginning of the epidemic 
of syphilis in Europe ; but even the systematic directions laid 
down for its application by Louvrier and Rust at the begin- 
ning of this century led to so much misuse, that all sensible 
physicians denounced it. 

Our method of employing the inunction-cure is the follow- 
ing : "We begin the inunctions without any special preparations, 
simply allowing the patient to take a lukewarm bath. We 
order from two to five grammes [ 3 ss. to 3 jss.] of blue-oint- 
ment for each inunction. The inunctions may be performed 
by the patient himself, or by an attendant with leather gloves 
upon his hands. They may be resorted to daily, or every 
second or third day, according to the intensity of the syphilitic 
lesion and the constitution of the patient, and are carried out 
in the following order upon the various parts of the body : 

On the first day of the treatment the ointment is rubbed 
in on the anterior surfaces of both arms ; on the second day, 



SYPHILIS. 359 

on the anterior surfaces of both thighs ; on the third day, on 
the anterior surfaces of both forearms ; on the fourth day, on 
the anterior surfaces of both legs ; on the fifth day, on both 
loins ; on the sixth day, on the back ; on the seventh day, 
the order of arrangement is begun anew. The patient should 
thoroughly rub in the whole dose of the salve, taking care that 
none of it remains in lumps upon his hand or upon the body. 
The hairy parts of the body should be avoided as much as pos- 
sible, because the inunctions are there apt to produce an erup- 
tion of small pustules, an inflammation of the apertures of the 
hair-follicles. If the patient's hands are tough and callous, he 
should put on a pair of tight-fitting leather gloves wherewith 
to perform the inunction. 

In unpleasant weather the patient should remain in his 
room ; but when the weather is favorable, especially during 
the warm season of the year, he should spend the greater part 
of the day out-of-doors. During the cold season, the tem- 
perature of the room should be 15° or 16° Reaumur [6Q° or 68° 
Fahr.], and, if possible, the apartment should be thoroughly 
ventilated twice a day. 

The physician should pay special attention to the condi- 
tion of the mouth of the patient. From the very beginning 
of the treatment, the latter should be instructed to rinse his 
mouth repeatedly during the day with pure water, or water 
containing some astringent remedy, such as chlorate of potash, 
alum, borax, tannic acid, laudanum, etc., I'M [grs. xvj] to lOO'OO 
[^iij, 3viij] of water. In addition, he should prevent the 
formation of tartar on Ins teeth by brushing them several times 
daily with a soft tooth-brush and water. 

In accordance with the views already enunciated, we only 
resort to the inunction-treatment in the advanced stages of 
the disease, and especially in those cases which resist the action 
of less powerful remedies — the iodides. All relapses of the 
first phase of syphilis, such as relapsing papular syphilides, pso- 
riasis palmaris diffusa, impetigo, and ecthyma syphilitica, and 
partly, also, nodular syphilides, are particularly well adapted 
for treatment by inunction. In some cases certain special 
physiological and pathological conditions that may obtain will 
serve to determine the physician in preferring the inunction 



360 PATHOLOGY AND TREATMENT OF SYPHILIS. 

method over any other form of mercurial treatment. Thus, it is 
vastly preferable to subject syphilitic pregnant, and puerperal 
women to an inunction-cure, than to administer mercury to 
them internally. Persons having feeble digestive organs, those 
suffering from suspicious laryngeal and bronchial catarrhs, from 
frequent gastro-intestinal catarrh, or those who only recently re- 
covered from typhoid fever or dysentery, are more advan- 
tageously treated by inunctions than by the internal admin- 
istration of mercury. Further, the morbid syphilitic condi- 
tions best adapted for the inunction-treatment are those which 
are complicated with constitutional or other affections that 
also require internal treatment — for instance, scrofula, tuber- 
culosis, chlorosis, intermittent fever, etc. In these cases, cod- 
liver oil, iron, and quinine, may be employed in addition to 
the inunctions of mercury ; but the inunctions are principally 
applicable in those cases in which dangerous symptoms su- 
pervene, because they afford such rapid relief : thus, in sup- 
puration of the nasal passages, in iritis syphilitica, specific 
affections of the head, brain, and nerves, especially those that 
depend upon extra-cerebral morbid changes. 

The number of inunctions that may be necessary varies, of 
course, according to the form and intensity of the disease ; the 
individual condition of the patient ; and, lastly, whether the pa- 
tient had taken mercury shortly before beginning the inunction- 
treatment or not. 

The treatment of syphilitic ulcers, nodular syphilides, and 
large tophi, will require more inunctions than that of a papular 
syphilide. In regard to the individuality, experience has shown 
that there are persons in whom the employment of this method, 
and the mercurial treatment generally, exercise a favorable in- 
fluence upon the involution of the morbid phenomena in a 
very few days, while in others the lesions obstinately resist all 
kinds of mercurial medication. Fewer inunctions will be re- 
quired if employed in conjunction with Zittmann's decoction 
than without the aid of the latter. We have seldom found 
less than twelve to sixteen inunctions sufficient, nor more than 
thirty required in the patients that came under our observa- 
tion. If this number is not capable of subjugating the most 
essential features of the disease ; still more, if an aggravation 



SYPHILIS. 361 

of the syphilitic symptoms, or of the general condition super- 
venes, the treatment should be suspended for the time being, 
and an effort made by a proper diet and mode of living (some- 
times by the intercalation of a moderate grade of cold-water 
cure) to invigorate the system. When this has been achieved, 
the inunctions of mercury may be resumed. 

Sometimes it becomes necessary to suspend the inunction- 
cure for a time, owing to the supervention of certain physio- 
logical or pathological conditions. The physiological condi- 
tions referred to here are menstruation and confinement. The 
acute, febrile, contagious exanthemata, measles, scarlet fever^ 
variola, acute inflammations of some of the organs, intense 
catarrhal or inflammatory affections of the intestinal canal, ac- 
companied by exhaustive diarrhoeas, may be classed among the 
pathological conditions. Above all, however, an intercurrent 
haemoptysis in tuberculous syphilitic patients will require the 
immediate suspension of the inunction-treatment. But the 
application of the mercurial ointment per se not infrequently 
gives rise to morbid phenomena, which necessitate a suspen- 
sion of the procedure. Stomatitis mercurialis is one of the 
most frequent pathogenetic effects of mercury ; next in fre- 
quency are eczematous affections of the skin, occurring in hairy 
individuals on the places where the ointment is rubbed in, and 
in blondes with a tender skin over a larger part of the integu- 
ment. 

During the inunction-treatment the patient should be nour- 
ished with easily digestible food in quantities proportionate to 
his age, habits, and bodily conformation. We allow the pa- 
tient in the morning either a cup of tea, coffee, or a bowl of 
broth or milk, with one or two slices of wheaten bread ; for 
dinner, nutritious beef-soup, from fifty to seventy grammes 
[ 5 jss., 3 iv to § ij, 3 viij] ; veal, or chicken, twenty grammes 
[ 1 ss., 3 iv] ; rice boiled in milk or water, or some other di- 
gestible farinaceous food, or spinach in the same quantity ; even- 
ings, the patient gets another bowl of concentrated broth, with 
wheaten bread and coffee, chocolate, or milk. Special condi- 
tions, such as pregnancy, confinement, scorbutus, convalescence 
from typhoid fever, and intermittent fever, require special 
dietary regulations. Pure cold spring-water is the best drink 



362 PATHOLOGY AND TREATMENT OF SYPHILIS. 

that can be recommended. In the hot season of the year the 
patients, especially scorbutic convalescents, may be permitted 
to drink lemonade or water flavored with some fruit-sirup. 
Those who have been greatly reduced in strength by a pre- 
ceding typhoid or intermittent fever, loss of blood, or vicious 
mode of life, may be allowed to drink a proper quantity of 
good wine. During the inunction-treatment the patient's bow- 
els should move at least once a day, because experience has 
shown that those suffering from constipation are more liable to 
be affected with salivation than those who are not constipated. 
If the bowels are sluggish, cathartics or some mineral water 
that contains sulphate of magnesia or Glauber's salts, such as 
Saidschiitz, Piillna, Ofner, Elizabeth Spring, or the like, should 
be ordered. During treatment we often give a small quantity 
of Zittmann's decoction. 

If no contraindication against the continuation of the in- 
unction-treatment supervene, it should be prolonged till the 
physician has good reason to believe that the disease is entirely 
cured. The good effects of an inunction-cure, and of the 
internal use of mercury, soon manifest themselves by the fact 
that the patient loses his former cachectic appearance, gains 
perceptibly in weight, acquires a healthy color, and the evi- 
dences of the syphilitic diathesis capable of undergoing resolu- 
tion disappear. So long as the circumscribed discolored spots 
have not totally disappeared, so long as the syphilitic scars 
have not become perfectly pale, so long as there is falling out 
of the hair and fragility of the nails, the patients can not be 
deemed entirely cured. 

When the inunction-cure is completed, the patient should 
take one or more warm baths, protect himself against catch- 
ing cold by remaining a few days more in a warm room, and 
then may gradually resume his usual mode of living. To 
avoid all possible risks of the effects of a lowering temperature 
upon the system that may have become sensitive during the 
treatment, several hot vapor- baths, with subsequent cold douch- 
ing, or a moderate grade of cold-water treatment, may be rec- 
ommended to the patient. 

[The problem at the outset in the treatment of syphilis is 
to free the system of a poison that possesses the property of 



SYPHILIS. 363 

tenaciously clinging to it and of undermining it for years, per- 
meating all the tissues and fluids of the body. "We must bear 
in mind that so long as the poison is active the natural recu- 
perative powers of the body are insufficient to overcome the 
disease which has a tendency in many cases to be aggressive, 
progressing in its morbid changes, and, when left to itself, 
causing serious damage to many important organs. If the sys- 
tem is to be saved from permanent injury, if it is to be freed 
from the syphilitic poison and cured perfectly, the physician 
and patient must unite and continue their work together per- 
sistently until it is brought to a happy termination. 

The antidotes to the syphilitic poison are mercury and 
iodide of potassium ; upon that point there is no longer any 
question. The best authorities are now agreed that the disease 
can not be cured effectually without them. But they are only 
antidotes when properly handled. If given in insufficient 
doses, the disease soon obtains the mastery; if used in ex- 
cess, they become poisons themselves. To hit the exact and 
happy medium, to avoid both dangerous extremes, we must 
not confine ourselves to strictly arbitrary doses, but admin- 
ister them in quantities not only sufficient to control, but to 
eradicate the disease, in accordance with the requirements of 
each individual case, being ever ready to reduce the quan- 
tity or discontinue it entirely as soon as any untoward symp- 
toms manifest themselves. At the same time we must avail 
ourselves of such other agents as will aid in bringing about 
the transformation of diseased into healthy tissues, by increas- 
ing their nutrition with healthy blood, and removing effete 
matter — i. e., by a generous diet, diaphoretics, tonics, etc. 

To Yon Sigmund belongs the credit of having pointed out 
the fact that in the treatment of syphilis with mercury we 
must not only not produce any signs of mercurial poisoning, 
but the more perfectly we guard the system against the toxic 
effects of this drug the surer shall we be to cure our patient of 
his syphilitic disease. In the vast majority of cases the inunc- 
tion method is the best form of employing mercury, and, hav- 
ing obtained the most satisfactory results from it, I seldom 
use any other. In regard to the fear of patients taking cold 
during its employment, all I can say is that I have repeatedly 



364 PATHOLOGY AND TREATMENT OF SYPHILIS. 

seen patients come to my clinic in inclement weather with a 
considerable amonnt of mercurial ointment still fresh upon 
their persons, having neglected to wash it off for days to- 
gether (though they were cautioned against such a course) — 
many of them being insufficiently clad at that, without suffer- 
ing any ill effects from it. 

In the inunction-treatment, the following additional prac- 
tical suggestions may be of value to the practitioner : 

1. The body should be prepared to absorb the mercury, 
and a quantity of blue-mass used sufficient to produce an effect 
upon the syphilitic lesion. 

The preparation of the body simply consists in the patient 
taking a warm-water bath before rubbing in the salve ; he 
should remain in the bath from a quarter to half an hour. 
Poor patients who can not procure these baths should wash the 
part of the body upon which the salve is to be rubbed with 
diluted alcohol or vinegar and water, and afterward rub the 
part dry with a coarse towel ; in fact, simply rubbing the skin 
with a coarse dry towel accomplishes the same object — of stim- 
ulating the absorbent powers of the skin — as the use of hot 
baths. Sometimes, however, various obstacles may inter- 
vene, such as mercurialization and febrile phenomena, caused 
perhaps by a local affection, which have to be removed before 
the patient can be subjected to the inunction method. Para- 
doxical as it may seem, yet it is nevertheless true that a pa- 
tient may be brought to a state of mercurialization and sto- 
matitis without being benefited in the least, and it will be 
necessary to cure him of these complications before it is pos- 
sible to administer any more mercury to him. If the febrile 
phenomena are due to an intercurrent acute disease, or the 
patient has been intemperate, and indulged in excesses, it will 
be necessary to defer the inunction-treatment till his system 
has had an opportunity of recuperating somewhat, and been 
improved by proper restrictions, baths, tonics, etc. 

I deem the manner of rubbing in the ointment of the ut- 
most importance. Usually the patient takes a lump of salve 
and rubs it in upon his person without care or attention, leav- 
ing perhaps half of it in lumps on the skin or on his fingers. 
Naturally, little or no good is derived from such inunctions. 



SYPHILIS. 365 

the disease remaining unaffected — nay, more, often progresses 
unchecked. I therefore give him explicit instructions to rub 
the salve into his groins, thighs, or axillae, in such a man- 
ner that the whole mass of ointment is thoroughly rubbed 
away — consumed, as it were — and none remains on his lingers 
or in lumps on his body. If possible to employ a trained 
nurse to do the inunction, better results will, of course, be at- 
tained than when the patients do it themselves. If time per- 
mits, I order the patient to rub in the salve leisurely on one 
side first, and then on the other ; in this manner he is sure to 
rub it in more thoroughly than when he rubs it on both sides 
simultaneously. In order to avoid irritating the skin, I cause 
the salve to be rubbed in each day on a different part of the 
body, as recommended above. The amount of unguentum 
hydrargyri necessary for each inunction varies with the size of 
the body and susceptibility of the individuality — from 2*00 to 
5'00 (grs. xxx to lxxv) for an adult, and from 1*00 to 2*00 
(grs. xvj to xxx) for a child. 

A very good method I have found is to order the patient 
to rub in the required amount of the ointment just before go- 
ing to bed, drink a pint of hot milk, get into bed, wrap him- 
self up in blankets, and sweat. In the morning he should take 
a bath, or at least wash the part where the salve was rubbed in 
with warm water and soap. The hot milk is both nutritious 
and sudorific, and is an invaluable adjuvant in helping the 
system to get rid of the syphilitic virus. One great advantage 
of this method is that no patient is so poor that he can not 
provide himself with the agents necessary to carry it out. The 
rubbing in of the salve before going to bed does not interfere 
with his vocation, and his remaining in bed the whole night 
obviates the danger of his taking cold. For the sake of greater 
cleanliness, I sometimes use the oleate of mercury, but the 
objection to unguentum hydrargyri on the score of uncleanli- 
ness is obviated if the patient uses the same night-shirt while 
undergoing the course of inunction. 

2. The body must be maintained in a good state of health 
during the treatment. 

Above all things, it is necessary that the patient should 
breathe plenty of good air. The lungs must work in a good 



366 PATHOLOGY AND TREATMENT OF SYPHILIS. 

atmosphere, while the skin is impressed into service and com- 
pelled to absorb the antidote against the syphilitic poison. 
The patients should be out in the open air as much as possible, 
and sleep in as large a room as they can obtain. In small rooms 
more or less of the vapor of mercury accumulates in the air, 
and a tainted atmosphere is thus inhaled. For this reason, 
also, no one should share the room with the patient. The 
physician should insist upon the patients' taking sufficient 
out-of-door exercise, and properly ventilating the room they 
sleep in ; the fear of taking cold is so great that they often 
go to the opposite extreme, shutting themselves up in small, 
poorly ventilated rooms, and thus do themselves great in- 
jury- 

In regard to nutrition, it is only necessary to say that syphi- 
lis ushers in an acute anaemia, which saps and vitiates the sys- 
tem of the patient in proportion to the severity of the disease ; 
the debility is proportional to the loss of bodily weight. Hence 
the necessity of placing the patient upon the best possible diet. 
The brilliant results which the inunction-cure and low diet 
achieved in former years can not be set up against this prop- 
osition A sufficient amount of good and nutritious food 
should be allowed ; I am even in favor of according the 
privilege of partaking of a moderate amount of good wine or 
malt liquor daily, for the purpose of stimulating digestion 
and assimilation, and thus expediting the metamorphosis of 
the tissues by a better and richer blood-supply. However, 
owing to the gluttonous habits of some individuals, it will be 
well for the physician to prescribe for the patient the amount 
of food and drink necessary for him. It is of the utmost im- 
portance that he should not overtask his digestive organs, for 
upon the ability of the latter to prepare a proper pabulum will 
depend the recuperation of the entire system. 

It is highly essential that the mucous membrane of the 
mouth be maintained in a good, healthy state, and the tendency 
to mercurial stomatitis be obviated by appropriate local treat- 
ment. There is great diversity among patients in this re- 
spect. Some are very prone to suffer from mercurial stoma- 
titis, and others remain exempt from it throughout the whole 
course of the disease. But whenever the tendency manifests 



SYPHILIS. 367 

itself it should be counteracted by the use of some of the 
remedies mentioned above. If ulcers form in the mouth, they 
should be cauterized with nitrate of silver or chromic acid — 
the latter solution being employed one hundred grains to a 
drachm. In addition to this treatment, the patient must be 
enjoined to keep his mouth perfectly clean, and renounce the 
use of tobacco absolutely. 

I wish to say here that it is possible to habituate patients 
to the use of mercury, however sensitive they may be to it, 
and, if such a person comes under treatment, it is best to be- 
gin with a small quantity of mercurial salve and gradually 
increase it. If perchance salivation has been produced, the 
inunction should be suspended altogether till all the symptoms 
of mercurialization have disappeared. 

Sometimes it is difficult to distinguish mercurial from 
syphilitic ulcerations. Both occur on various parts of the mu- 
cous membrane of the mouth and resemble each other very 
closely. This is especially true of mercurial ulcers that oc- 
cur on the tonsils and palate. Here the matter can only be 
decided by time, watching the case carefully, and, if necessary, 
suspending the inunctions for a while. If the ulcers are mer- 
curial in origin, they will get well by the use of the above- 
described lotions for the mouth, but if syphilitic they will 
constantly become aggravated. They also act quite differently 
in reference to cauterizations. A syphilitic ulcer will get well 
— a mercurial ulcer becomes aggravated by cauterization. An 
increased flow of saliva may also cause uncertainty in regard to 
its origin, for sometimes cases are met with in which this con- 
dition is simply due to irritation of the nerves of the mucous 
membrane of the mouth and of the sab vary glands by the 
syphilitic virus. This point, however, can be decided by the 
history of the case and whether the patient has been subjected 
to a treatment with mercury or not. 

Another objection has been urged against the inunction 
method, namely, the production of sleeplessness. But, on in- 
vestigation, I have found that it is not of sufficient conse- 
quence to cause a suspension of the treatment. It occurs 
very seldom, and its effects are transient. I am, moreover, 
of the opinion that it is due to the general nervous irritation 



368 PATHOLOGY AND TREATMENT OF SYPHILIS. 

of the system caused by the syphilitic virus, as is manifest by 
the loss of sensibility of the cutis, and by the dilated pupils, 
and is therefore a still greater indication for persevering with 
the treatment. 

A word or two in reference to the local treatment of syphi- 
litic lesions during the inunction-cnre. Although the latter 
will almost always prove sufficient to cause ulcerations of 
the skin and other parts to heal, still a proper local treatment 
will be found of the utmost advantage. Above all, the sores 
are to be kept scrupulously clean, in whatever stage of the 
disease and upon whatever part of the body they may be. 
Solutions of bichloride of mercury, of carbolic acid, nitrate of 
silver, iodoform, boracic-acid ointment, etc. — any one of these 
will render efficient service. For the nose, vagina, or rectum, 
Esmarch's irrigator will be found indispensable. 

3. The inunctions must be continued long enough. 

To cause the morbid lesions to heal, and prevent relapses — 
that is our task. The earlier the syphilitic patient is taken in 
hand, and subjected to a thorough anti-specific treatment, the 
milder the disease will run its course, and the more rapidly 
will the symptoms disappear. I have seen so many hard, initial 
sclerotic nodes, or hard chancres, attended by indurated plaques 
of inguinal glands, disappear, melt away as if by magic under 
the inunction-treatment, the patients remaining subsequently 
free from relapses, that I no longer hesitate to put a patient 
under the specific inunction-treatment as soon as I have 
satisfied myself of the true nature of the lesion. It is con- 
ceded by some of the best authorities that it is easier to cure 
a patient radically of his syphilis while the infecting virus is 
still localized in the initial sclerosis, or even if it has affected 
the inguinal lymphatic glands, than when it has permeated 
his entire system, less medicine and a shorter time being neces- 
sary to counteract a poison confined to a limited space than 
when diffused throughout the tissues and fluids of the body. 
I prefer the inunction method for this purpose, because I can 
accomplish more with it in a given time than by the internal 
administration of mercury. Besides, it possesses the additional 
advantage over the latter of not interfering with the patient's 
digestion. The complications of the inunction-cure spoken of 



SYPHILIS. 369 

above are only seen in exceptional cases, and have been referred 
to at length because of the greater value it possesses over other 
methods of treatment. I quite agree with Yon Sigmund in his 
statement that there will scarcely ever be seen a case of syphi- 
lis which the inunction method, if continued long enough, 
will not cure eifectually. It is well to state here that, to cure 
a patient radically, and render him proof against relapses, it is 
necessary to prolong the inunctions of mercury for from eight 
to ten days after the symptoms of syphilis have entirely dis- 
appeared. 

One of the most useful adjuvants in the treatment of syphi- 
lis is the hot-air bath, Russian or Turkish. The use of topical 
bathing before and after the rubbing in of the mercury has al- 
ready been alluded to. The hot-vapor bath for the purpose of 
causing profuse diaphoresis is an invaluable remedy. I cause 
my patients to take one and often two a week. It is well to 
caution them against remaining too long a time in the hot-air 
chambers, fifteen or twenty minutes being sufficient to cause 
active turgescence of the skin, attended by a profuse flow of 
perspiration. A longer stay will relax the system too much 
and prove debilitating. The physiological action of these 
baths is that of a derivative of the greatest power, and their 
good effects are soon manifest. 

A word or two more in reference to the use of the iodides. 
Everything that has been said concerning the susceptibility of 
certain individuals to the use of mercury is applicable with 
still greater force to the preparations of iodine. Often they 
are tolerated badly, or not at all, even when taken after meals 
and largely diluted. Thus, in one patient, it was impossible 
to administer the remedy unless it was preceded by a teaspoon- 
ful of brandy largely diluted with water. The individual was 
not of intemperate habits. In other patients, again, the dose 
required to produce a physiological impression upon the sys- 
tem, to bring about a state of iodism, may vary in amount 
from 0*60 to 4*00 (grs. x to 3 j) every three or four hours. 
Many physicians prescribe small doses of the iodide in com- 
bination with mercury, even for the early manifestations of 
the disease, in what is denominated the " mixed treatment," 
each dose containing about 0*01 (gr. -fa) of corrosive sublimate, 
24 



370 PATHOLOGY AND TREATMENT OF SYPHILIS. 

and 0*30 (grs. v) of iodide of potassium, properly diluted. 
When an important organ is involved and is in danger of -be- 
ing irreparably damaged, full doses of the drug — from 1-00 
to 4*00 (grs. xv to 3 j) three or four times a day — will render 
efficient service ; likewise, when the use of the mercury has 
to be suspended and it is necessary to prolong its specific effect. 
On account of its rapid action, it is especially useful in those 
terrible night-pains that sometimes threaten to drive a patient 
to distraction. Finally, the remedy is often serviceable in de- 
tecting the true nature of an obscure syphilitic lesion. The 
many cases of nervous affection whose etiology is so difficult 
to elucidate, and in which cures are reported to have been 
achieved, are doubtless of syphilitic origin. Patients are often 
met with who form their own diagnosis by the statement that 
iodide of potassium has repeatedly relieved them of their dis- 
tressing ailment, thus affording the physician an indication 
of the true nature of their disease. Thus, one patient informed 
me that he had been suffering for five years from the most 
violent pains in his stomach and frequent emesis, which was 
always controlled by iodide of potassium ; and, on inquiry, I 
found that he had had a chancre some eight years before, fol- 
lowed by a slight syphilitic eruption, but supposed himself to 
be entirely cured of his disease. 

It may be remarked en passant that the remedy is often 
abused. Many of the morbid lesions of this disease get well 
under its use, and thus the patient becomes accustomed to 
resort to it whenever anything happens to him. In the 
course of time he finds, greatly to his surprise, that the 
remedy makes no impression upon the disease, the symptoms 
remaining stationary, or even becoming aggravated, a condi- 
tion of tolerance having taken place ; not only has the iodide 
lost its power over the disease, but it may happen that, when 
the patient submits himself to radical treatment, such as may 
become necessary upon the supervention of some acute specific 
lesion, he is extremely unimpressionable to the action of the 
remedies. A longer or shorter interval of abstinence from all 
medication will then be necessary before the remedies can ex- 
ert their power over the disease.] 



SYPHILIS. 371 

(b) Hypodermic Mercurial Treatment of Syphilis. 

Lewin was the first physician who systematically practiced 
hypodermic injections of corrosive sublimate in the treatment 
of syphilis, though many had employed various preparations 
of mercury subcutaneously before him. 

Before we relate the results of our experience with hypo- 
dermic injections, we desire to say a word concerning the 
technique and the precautions that are necessary. A broad 
fold of skin should be pinched up and made as tense as pos- 
sible, because the point of the hypodermic needle will then 
penetrate the skin much more easily, the pain will also 
be lessened, and a vacuum is thereby created over a com- 
paratively large surface for the absorption of the injected 
fluid. These factors obviate, to a great extent, the danger of 
the formation of an abscess. The oiling of the needle be- 
fore injecting the medicine is superfluous, but the entire in- 
strument should be cleansed in water and dried before each 
operation, so that the canula does not become rough and 
clogged up, and particles of corrosive sublimate forced into 
the skin. The piston should work smoothly, failing in which, 
and if much force has to be used, there is danger that the op- 
posite fold of skin will be punctured, and the injected fluid 
penetrate into, instead of under, the skin. In injections with 
corrosive sublimate, such an accident is liable to be attended 
by unpleasant results ; the puncture becomes inflamed, suppu- 
rates, and causes severe pain. The skin should be punctured 
and the entire injection performed as quickly as possible. In 
corpulent persons the injections, it is true, are made with more 
difficulty ; still, they can be performed if a fold of skin suf- 
ficiently broad is pinched up. We have never seen any bleed- 
ing from puncture of a blood-vessel. 

In regard to the frequency of salivation, we must say that 
gingivitis and stomatitis did not occur oftener in the patients 
we treated by hypodermic injections than in those treated by 
inunctions with mercury. Relapses and successive outbreaks 
of syphilitic phenomena occur just as often in the injection- 
treatment as in that by inunctions. It is a curious fact that if 
gingivitis develop during the mercurial inunction method, the 



372 PATHOLOGY AND TREATMENT OF SYPHILIS. 

pyramids of the incisor teeth of the lower jaw, as a rule, are the 
first to swell up, while in the treatment by hypodermic subli- 
mate injections gingivitis of the upper incisors usually develops 
first. If the injections are made in the vicinity of the pri- 
mary induration and indolent absorption buboes in the groin, 
the latter will be the first to disappear ; ulcerating papules offer 
the greatest degree of resistance to the hypodermic injections. 
The maximum of a total dose of 0*2 [grs. iij], either of calo- 
mel or of bichloride, was needed only in the most obstinate 
cases. 

In regard to the choice of the mercurial to be used, we 
prefer corrosive sublimate to calomel, although, as a rule, we 
have seen the syphilitic phenomena disappear sooner from the 
use of calomel injections. But this advantage which calo- 
mel possesses is greatly offset by the fact that the injections 
are almost always followed by boils, despite the utmost care 
adopted. Although they did not always suppurate, still they 
were very painful for a long time. According to the statement 
of the patients, the pains last longer after injections with a 
purely watery solution of sublimate than when the watery so- 
lution is mixed with glycerine. Gingivitis, as a rule, comes 
on later in injections with corrosive sublimate than with 
calomel. 

"We use the following formula : 

IJ Sublimat. corrosivi, 1*00 [grs. xvj]; 
Glycerini puri, 70*00 [ § ij, 3 viij] ; 
Aqua destil., 30-00 [ § j]. 
M. S. For injections. 

A syringeful of this solution contains 0*01 [gr. £]. The 
injections should be made into the back and sides of the 
thorax. 

Some physicians — Legeois, for instance — fearing the corro- 
sive effects of the sublimate, have injected a minimum dose, 
0*005 [gr. -j^], combined with muriate of morphia. Dr. 
Staub, of Strasburg, employed for that purpose, a preparation 
of corrosive sublimate free from acid. He dissolved the sub- 
limate and chlorate of ammonium in distilled water, and fil- 
tered the solution ; next he dissolved the white of an egg in 



SYPHILIS. 373 

distilled water and filtered it ; lastly, lie mixed both solutions, 
and filtered for the third time. Cullingworth found Staub's 
solution, aside from the trouble of preparing it, exceedingly 
liable to become decomposed, and injections made with it were 
followed by indurations that disappeared very slowly. No 
indurations, however, followed the use of solutions obtained by 
the method described by Yon Bamberger, in 1876, and many 
patients treated alternately with Staub's and Bamberger's solu- 
tions maintained that the latter preparation is much less pain- 
ful. In Bamberger's solution pepton is used in place of 
albumen, which simplifies its preparation, and renders it 
more permanent. He dissolved 1*00 [grs. xvj] of meat- 
pepton in 50 ccm. [ § j, 3 v] distilled water, and filtered the 
solution. To this he added 20 ccm. [ 3 v] of a five-per-cent 
sublimate solution, and dissolved the resulting precipitate with 
the requisite quantity (15 to 16 ccm. [ 3 iv]) of a solution of table- 
salt, poured the liquid into a graduated glass, and added dis- 
tilled water till the whole amounted to 100 ccm. [ 5 iij, 3 ij]- 
Every cubic centimetre then contains exactly 0*01 [gr. -J-] mer- 
cury combined with pepton. The liquid should be covered 
and allowed to stand quietly for several days. A slight amount 
of white flaky precipitate settles, from which it is finally sepa- 
rated by filtering. This preparation keeps better than the al- 
buminate, and injections made with it only cause so much pain 
as is experienced from the sudden tension of the subcutaneous 
connective tissue. Other physicians (Boulton, for instance) 
inject iodide of mercury in a solution of iodide of potassium. 
Still others have tried various other preparations of quick- 
silver for injections, especially hydrarg. acet., hydrarg. ioda- 
tum, and hydrarg. biniodatum rubrum, and, lastly, a watery 
solution of iodide of potassium containing the protoiodide. 

But the last-mentioned injecting fluid is now almost en- 
tirely abandoned, as it is liable to be precipitated and act as an 
irritant. Lately, the chromate of the oxydul of mercury and 
the methyloxydhydrat have been tried ; we have had no ex- 
perience with these preparations. Cullingworth, Yon Sig- 
mund, and Gurtz recommend hydrarg. bicyanetum. 

Quite recently a one-per-cent solution of mercury formcu- 
mid was recommended for subcutaneous injection by Lieb- 



37± PATHOLOGY AND TREATMENT OF SYPHILIS. 

reich. We have tried this preparation quite extensively. In its 
action it differs in no respect from other mercurial compounds ; 
it causes the symptoms of syphilis to disappear just as quickly, 
and also produces salivation as readily as other preparations of 
mercury, and the relapses, too, occur just as often after its 
use as after any other. 

The main advantage of the hypodermic mercurial treat- 
ment is that the dose of the medicine introduced into the sys- 
tem is not only very much smaller than that which is admin- 
istered by the mouth or in the inunction method, but it can 
also be measured accurately. Furthermore, it is also a much 
cleaner and less expensive method than the inunction or in- 
ternal treatment, circumstances which, in private or even hos- 
pital practice, can not be over-estimated. Nevertheless, we 
seldom resort to this method now, because it is by no means 
painless, is as little capable of preventing relapses, and just 
as often occasions mercurial stomatitis, as any of the other 
methods of administration. 

(c) Treatment of Syjphilis hy Mercurial Fumigations. 

For many years H. Zeissl and others treated their syphilitic 
patients in the Vienna General Hospital by mercurial fumiga- 
tions, according to the method described by Dr. Henry Lee, 
of London. The patient, entirely nude, is placed upon a cane- 
bottom chair and wrapped in a cotton gown provided with a 
hood, the face only being exposed. A funnel-like vessel, open 
below and perforated with holes all around, is placed under 
the seat. At one place it is cut out for the admission of a 
spirit-lamp. Above, the vessel is shut off by a plate which 
is depressed in the middle, where a small saucer is placed. 
The depression in the plate is filled with water for the purpose 
of generating steam-vapor, and in the saucer 1*50 [grs. xxij] 
of calomel is placed. On lighting the lamp, vapor, impreg- 
nated with the fumes of calomel, is generated and deposited 
upon the skin of the patient. Most patients feel very com- 
fortable during and after the fumigation, the respiration being 
in no way interfered with by the process. Directly after the 
fumigation they must go to bed, to avoid taking cold. 

The fumigations may be made every day, or every other 



SYPHILIS. 375 

day, or even at still greater intervals. The greatest number 
of fumigations necessary to perform a cure was fifty-five. 
Salivation occurred in ten cases. Relapses sometimes ensued 
after numerous fumigations. No syphilitic patients, who are 
liable to attacks of haemoptysis, should be subjected to the 
fumigation-treatment with mercury. AVe never employ this 
method now. 

(d) Treatment of Syphilis with Baths containing Mercury. 

Corrosive sublimate is the only preparation used in treating 
syphilitic patients with baths containing mercury in solution, 
and by the addition of muriate of ammonia it is rendered more 
soluble. The following is the formula we use : 

5 Sublimat. corros., 15*00 [ § ss.] ; 
Mur. ammonia, 5 -00 [3 iv] ; 
Aqua destil., 100-00 [ | iij, 3 viij]. 
M. In vitro bene obturato. 

This solution is poured into a bath at a temperature of 
27° to 28° Reaumur [92° to 95° Fahr.]. The patient remains 
in it for about an hour and a half, during which time it is cov- 
ered so that only his head is exposed. Corrosive-sublimate 
baths are adapted for individuals whose skin will not bear in- 
unctions, whose respiratory organs do not tolerate inhalations, 
and whose digestive organs rebel against the internal admin- 
istration of mercury. They are especially useful in patients 
suffering from pustular and ulcerating syphilis, and those in 
whom mercury when internally administered produces un- 
pleasant digestive disturbances. But they should not be em- 
ployed if the pustules are dry and exfoliate, and leave behind 
perceptibly hard perifollicular infiltrations — a phenomenon 
which we often had an opportunity of observing in variola 
syphilitica. 

While the sublimate baths are being used the same die- 
tary measures should be enforced as in any other method of 
mercurial treatment. These baths likewise are apt to occasion 
salivation. It is not possible to presage the exact number of 
baths that will be necessary in any given case. 

As the absorbing power of the skin is undoubtedly differ- 



376 PATHOLOGY AND TREATMENT OF SYPHILIS. 

ent in different persons, it is not possible to say how much sub- 
limate of mercury — which, as is well known, is a very active 
remedy — is absorbed, and hence this method is not likely to 
be extensively used. 

(e) Treatment of Syphilis by the Application of Mercurial 
Suppositories to the Mucous Membrane of the Bectum. 

In many cases H. Zeissl has used suppositories of unguen- 
tum hydrargyri by way of experiment, in the following form : 

B Ung. hydrarg., 1*50 to 3*00 [grs. xxirj to xlvij]; 
Ung. ceti., 5-00 [3 iv]. 
M. Ft. sup. No. IV. 

The patient inserts one of the stronger suppositories in the 
evening into the rectum, and of the weaker suppositories one 
in the morning and one in the evening. By this method of 
applying the mercury we have often caused recent relapses of 
papular eruptions to disappear. In some cases evidences of 
beginning disease of the mucous membrane of the mouth — sto- 
matitis were produced. The mucous membrane of the rectum 
was not directly affected by the suppositories. 

Pathogenetic Effects which Mercury and its Preparations may 
produce during Treatment. 

In some persons, the preparations of mercury, like the pure 
mineral, when introduced into the system, produce in a re- 
markably short time, in others after a longer period, certain 
morbid effects. Collectively, the phenomena produced by the 
toxic effect of quicksilver have been described by the name of 
mercurialism, hydrargyrosis, or quicksilver-disease. An acute 
and chronic hydrargyrosis is distinguished, and according as it 
is produced by the industrial use of mercury or by medicinal 
application it is known as industrial or medicinal hydrargy- 
rosis. The latter manifests itself by a peculiar affection of the 
mucous membrane of the mouth, namely, stomatitis mercu- 
rialis. We have never seen any ulceration of the skin or dis- 
ease of the bones, or paralysis, in consequence of the thera- 
peutic use of mercury, even in cases in which its misuse was 
carried to the extreme. 



SYPHILIS. 377 

Mercurial affection of the oral mucous membrane mani- 
fests itself usually by an unpleasant metallic taste in the mouth. 
The patient has the sensation as if the teeth are blunted 
and elongated, and of dryness in the mouth. An effort to 
chew solid food causes pain and slight bleeding of the gums. 
Gradually the patient finds that he wants to spit often. If at 
this time pressure is made upon the submaxillary gland, pain 
will be experienced, because the gland is somewhat enlarged. 
The gums, especially of the lower incisors (less of the upper), 
the lips, the mucous membrane of the cheeks, especially around 
the mouths of the mucous follicles, are of a bright-red color, 
swollen, and in places ecchymotic. The edges of the gums are 
livid, tumefied, surround the individual teeth like a wall, and 
separated from them ; and for that reason they seem to the 
patient to be elongated and loose. In the spaces between the 
teeth the secretion of the glandulse tartricas accumulates, in 
the form of a sticky, yellowish-green, offensive substance. The 
secretion of saliva increases more and more, and becomes an 
actual salivation. Lastly, the tongue swells, and becomes cov- 
ered with a dirty, slimy coating. The patient experiences dif- 
ficulty in moving the organ, and it sometimes attains to such 
a size that the mouth is not large enough to contain it, so that 
the apex protrudes between the incisor teeth, and the lateral sur- 
faces bear the indentation of the rest of the teeth (lingua cre- 
nata). The patient suffers from thirst, and the large quantity 
of saliva which he swallows sometimes causes nausea and vom- 
iting. If the action of the mercury is not arrested, and if the 
patient in addition is subjected to such influences as will nat- 
urally occasion stomatitis and scorbutus, the entire mucous 
membrane of the mouth will become coated with a grayish, 
diphtheritic layer, which can not be brushed off without caus- 
ing loss of substance. The mucous membrane finally also be- 
comes infiltrated and sloughs form, particularly on those places 
that are pressed upon by the teeth. When the sloughs are 
cast off considerable bleeding takes place, and then irregular, 
excavated, painful ulcers covered with a grayish coating origi- 
nate. The quantity of saliva secreted sometimes amounts to 
several kilogrammes [many pounds]. It is a remarkable fact 
that the saliva, according to some of the most eminent chemists 



378 PATHOLOGY AND TREATMENT OF SYPHILIS. 

(Schneider), contains very little or no mercury ; on the other 
hand, according to Kletzinsky, sulpho-hydrate of ammonia and 
traces of urea are found in it — the former apparently being the 
cause of the offensive odor. The teeth may ultimately become 
so loose that they fall out. In consequence of the mercuri- 
alization the soft parts of the lower jaw are sometimes de- 
stroyed by sloughing, periostitis ensues, followed by deposits 
of porous, pumice-stone-like substance, which are known by 
the name of osteophytes. 

Carious teeth, or other morbid conditions of the mouth, 
neglect and uncleanliness of the teeth and gums, cold and wet, 
and foul air, promote the development of stomatitis. In some 
persons salivation ensues after they have undergone a mild 
course, in others after a severe course, of mercury. It hardly 
ever occurs in infants and old, toothless persons. 

A slight mercurial affection of the mouth, and tenderness 
of the gums, is of no consequence. On the contrary, even 
the opponents of the salivation-cure do not object to it, because 
they deem it a favorable prognostic sign in regard to the cure 
of syphilis. But severe stomatitis, produced by prolonged and 
excessive use of mercury, may be followed by very sad results. 
By the sloughing of the lips, mucous membrane of the cheeks 
or tongue, irremediable loss of substance may ensue ; the mu- 
cous membrane of the lips may become united to the jaws, the 
tongue, or floor of the mouth, so that, on the one hand, the 
opening of the mouth, on the other, the movements of the 
tongue, may be prevented (Bamberger). 

In order to prevent the occurrence of mercurial stomatitis 
the patient should be informed at the commencement of the 
treatment of the prodromata of the disease, so that he may sus- 
pend its use as soon as they appear. Furthermore, the patients 
should be instructed to rinse their mouths several times every 
day during the time they are undergoing the mercurial treat- 
ment ; they should be cautioned against exposing themselves 
to a too high or too low temperature, and the room they oc- 
cupy should be carefully ventilated at least once a day. If 
the stomatitis is already fully developed, the patient should 
be removed, if possible, from the atmosphere that is impreg- 
nated with particles of quicksilver into a purer one. His 



SYPHILIS. 379 

clothes, utensils, etc., to which mercurial ointment may ad- 
here, should be removed, and he should be immersed in a 
warm bath. 

The local treatment depends upon the intensity of the 
affection. If the mucous membrane of the mouth is only 
catarrhally red or loose, the patient should be instructed to 
rinse his mouth every half-hour with one of the follow- 
ing lotions : 

5 Tr. opii, 5-00 [3 iv]; 

Aqua fontan., 500-00 [ § xv]. 
M. S. For gargle. 

5 Glycerini puri, 20-00 [ § jss., 3iv] ; 
Tannini puri, 5*00 [3iv] ; 
Aqua font., 500*00 [ § xv]. 
M. S. For gargle. 

Lotions for the mouth, consisting of solution of alum, bo- 
rax, tincture of rhatany, salvia, tormentilla, etc., are equally 
efficacious. When the salivation is severe, use — 

5 Tr. iodines, 5-00 [3iv]; 
Aq. fontan., 500-00 [ § xv] ; 
Aq. cinnamom., 

Syr. cinnamom., aa, 50*00 [ § jss., Biv]. 
M. S. Mouth-wash. 

Lotions composed of chlorine abolish the offensive odor of 
the mouth very rapidly. The following may be ordered for 
this purpose : 

B Chlorin. liquid., 10*00 [Bviij]; 
Decoct, althse, 500-00 [ f xv] ; 
Mel. rosarum, 50-00 [ § jss., 3iv]. 
M. S. Lotion. 

5 Kalichlor., 5-00 [2)ivj; 
Aq. font., 500-00 [ § xv] ; 
Syr. moror., 20-00 [§ss., Biv]. 
M. S. Gargle. 

If diphtheritic or gangrenous sloughing of the mucous 
membrane of the mouth has already taken place, either of the 
following may be ordered : 



380 PATHOLOGY AND TREATMENT OF SYPHILIS. 

5 Ext. ligni. campechiani., 20-00 [ § jss., 3iv]; 
Aq. fontis., 

Aq. salvias, aa, 200*00 [ § vj, 3 vss.]. 
M. S. A lotion for the mouth. 

3 Emuls. commun., 300'00 [ § ixss., 3 iv] ; 
Camphora., 3*00 [grs. xlvij]. 
M. S. A lotion for mouth, and for painting the gangrenous sores. 

If these remedies prove ineffectual, pyroligneous acid or 
chloride of calcium should be tried ; mixed with an appropri- 
ate amount of water, they may be used as a wash for the 
mouth and application to the ulcers. The diphtheritic patches 
may also be touched with nitrate of silver, or painted with 
tincture of iodine. Narcotics, especially opium, may be used 
locally and internally for the relief of the pain. If the bowels 
are confined, some laxative should be administered, and water, 
acidulated with some vegetable acid, may be given as a drink. 
In cachectic persons who are greatly debilitated, care should be 
taken to invigorate them as much as possible. 

Effects of Cold-Water Treatment, Sea-Baths, and Sulphur Ther- 
mal Baths on Syphilis and Hydrargyrosis. 

In regard to hydropathic treatment as a curative remedy 
of syphilis, most authors are now agreed that it is an excellent 
adjuvant to other therapeutic measures. But the hydropathic 
treatment accomplishes no quicker results in syphilis than 
the expectant method. Cold-water treatment and sea-baths 
are especially useful in those patients who become greatly 
enfeebled by syphilis, or who suffer in consequence of the 
injudicious administration of mercury. Sulphur -baths gen- 
erally have an excellent effect upon syphilitic patients. Under 
the use of sulphur thermal baths, the intense pains in the 
bones, especially, are greatly relieved. If the patients are suf- 
ficiently careful, some of the most obstinate syphilides, such as 
psoriasis palmaris, etc., will disappear more quickly with the 
use of the sulphur thermal, if appropriate anti-specific treat- 
ment is simultaneously carried out, than without the latter. 
Martineau recently asserted that sulphur-baths were a test of 
the persistence of latent syphilis. Still, should a relapse ensue 



SYPHILIS. 381 

in a syphilitic patient who was under treatment with sulphur- 
baths, it is no proof that the baths occasioned it. 

For a long time the use of sulphur internally and sulphur- 
baths were highly praised as remedies against hydrargyrosis, 
especially mercurial tremor. All we can say is, that we have 
obtained good results from sulphur-baths in persons who have 
not suffered long nor very severely from the tremor, and 
who, during the use of the baths, abstained from handling all 
kinds of mercurial preparations. It is possible that we would 
have obtained the same results from ordinary baths, but it is 
also probable that, by the use of the sulphur thermal, the tis- 
sues are stimulated to greater metamorphosis, and thus the 
quicksilver is more rapidly eliminated from the system. 

Syphilophobia and Mercuriophobia or Hypochondria Mercu- 

rialis. 

There are persons who, having suffered from syphilis or 
some other venereal disease, become a prey to feelings of de- 
spondency, which is best described by the term syphilophobia. 
They fear that they are still afflicted with syphilis, though not 
one symptom of it or any morbid alteration can be detected on 
their person. All rational attempts to convince them that 
they are free from the disease are useless. Day and night 
they busy themselves with their imaginary disease, and actually 
hunt for symptoms upon their persons, or conjure up some 
in support of their statement. " Thus they go about," says 
Eicord, correctly, " a burden to themselves and the whole world, 
ruin themselves by all sorts of cures which they practice upon 
themselves, or are induced so to do by ignorant or dishonest 
physicians." 

On the other hand, there are also hypochondriac persons 
who, having heard of the injurious effects that may be pro- 
duced by the improper use of mercury, imagine, when they 
ascertain that they took some of it, even the minutest quan- 
tity, that they will forever suffer the most dire effects. These 
persons think of nothing but their imaginary disease, neglect 
their affairs, and lose all interest in life. Any sensation they 
experience, any redness or swelling noticed by them ; some- 
times, indeed, perfectly normal elevations on the joints, bones, 



382 PATHOLOGY AND TREATMENT OF SYPHILIS. 

etc., such as the cristge tibiae, which they accidentally discover, 
are attributed to the mercury, taken perhaps many years be- 
fore. All the arguments that may be used to such psychical 
patients are in vain. The delusion that they are suffering 
from mercurial poisoning, and the hatred they entertain for 
the physician who gave them mercury, cling to them all the 
more if they have read mercurio-phobic writings, or are con- 
firmed in their views by mercurio-phobic physicians. "We 
have never yet found this psychopathy in persons belonging 
to the lower order of people, but only in those of the more 
affluent class. 

Syphilization. 

The treatment of syphilis by the method erroneously 
styled syphilization, has, since the death of Boeck, been entirely 
abandoned. Auzias Turenne first suggested it in 1844. He 
observed that, if a person is inoculated with the virus of a 
soft chancre for a long time, he will finally acquire an im- 
munity against the poison, and the subsequent inoculations 
fail to take. Such persons are said to be syphilized. But, as 
we know that the soft chancre and the syphilitic primary le- 
sion, or, as the French physicians call it, the infecting chancre, 
are two different morbid processes, like pneumonia and pleu- 
risy, we must, like Haye, call this method simply " curative 
chancroid inoculation." But a healthy person who has been 
inoculated with the matter taken from a syphilitic primary 
lesion and has had syphilis, may be said to be proof against 
syphilitic infection a second time, because we know that rein- 
fection with syphilitic virus is one of the rarest occurrences. 
A prophylactic and a therapeutic syphilization is distinguished. 
The former, it is claimed, acts in the same manner as vaccina- 
tion. In regard to the effect of the soft chancre upon a 
person already affected with syphilis, Haye says that the in- 
oculated chancroids are derivative foci, " exutoria," similar to 
those that may be produced by inoculations with croton-oil, 
tartar emetic, etc. These methods of treatment have been 
tried by Langenbeck, Hjort, and others. As we have al- 
ready said, this kind of prophylaxis and treatment of syphi- 
lis is not employed any more, and is only historically inter- 
esting. 



SYPHILIS. 383 

Treatment of some of the Local Syphilitic Affections. 

Among the morbid alterations that may be occasioned by 
syphilis there are some which, partly owing to the disturbances 
of sensation, partly owing to the mutilation and disfigurement 
they produce, require local treatment in addition to the treat- 
ment of the general constitutional disease. These are affec- 
tions of the organs of sight and hearing, the moist papules, 
mucous-membrane papules around the anus, on the genital or- 
gans, on the mucous lining of the mouth and fauces, syphilitic 
affections of the larynx and trachea, psoriasis paimaris and 
plantaris, deep ulcers of the skin and of the mucous mem- 
brane, solid and suppurating periosteal and osseous nodes, ab- 
scesses of the soft parts, caries and necrosis of a part of a bone, 
especially ozsena, perionychia, sarcocele syphilitica, strictures 
of the rectum, etc. 

In regard to affections of the organ of sight, we refer the 
reader to the section on syphilitic affections of the eye, by 
Professor Mauthner. 

Syphilitic affections of the ear require local treatment in 
accordance with the principles of otology. According to the 
statements of the most experienced otologists, the local treat- 
ment requires a long time before a cure can be accomplished, the 
general treatment being unable to achieve a satisfactory result. 

In regard to the local treatment of syphilitic affections of 
the larynx and trachea, we refer the reader to the therapeutic 
recommendations of Professor von Schrotter, in the section 
on those diseases. 

Mucous - membrane papules require different local treat- 
ment according to their site and metamorphosis. If they are 
situated in the mouth, and if, when they undergo degeneration, 
they assume only the form of erosions, simply washing them . 
with a mild, astringent lotion, will often suffice to bring about 
cicatrization. But if they have become transformed into deep 
ulcers, it will be necessary to touch them once or twice daily 
with lunar caustic, or they should be penciled with a solution 
of iodo-glycerine like the following : 
1$ Glycerine, 10-00 [3 yiij]; 

Kali hydroiod., 0'50 [grs. viij]; 
Iodine puri, 0*05 [grs. £]. M. 



384 PATHOLOGY AND TREATMENT OF SYPHILIS. 

Vegetations growing upon proliferating papules of the mu- 
cous membrane of the mouth, if they do not shrink after the 
application of astringent or caustic remedies, must be removed 
with the scissors and the wounds cauterized. 

Papules on the mucous membrane of the genital organs and 
rectum should be treated in the same manner, except that 
the j may be cauterized much more vigorously. 

Moist papules around the anus and genital organs require, 
above all, the utmost cleanliness, which can only be secured by 
frequently bathing or washing the parts. By inserting pledg- 
ets of lint between an affected and a sound part, the opposing 
surfaces are kept asunder, and the disease is prevented from 
spreading or infecting a normal part. Proliferating growths 
that frequently develop, and the fetid odor of the moist pap- 
ules, should be destroyed as speedily as possible. For this pur- 
pose a modified Plenk's paste is used now, which is composed 
according to the following formula: 

3 Sublimat. corros. ; 
Camphorse ; 
Aluminis ; 
Cerusse alb. ; 
Spirit, vim ; 
Aceti vini, aa 5'00 [3iv]. M. 

These ingredients, being partly or entirely insoluble in spirit 
of wine and acetic acid, are precipitated and form a soft paste ; 
the supernatant fluid is poured off, and the paste is applied 
with a small brush to the part which is to be cauterized. It 
causes little pain when first applied, but it soon becomes very 
severe ; and for the purpose of relieving it, and of preventing 
the swelling of the parts, cold-water compresses should be 
applied. Care should be taken not to allow the paste to get 
upon any part of the skin covering loose cellular tissue, such 
as the labia majora and minora, the glans penis, cervix uteri, 
etc., as it is apt to occasion intense inflammation of the parts, 
which swell up excessively and may become gangrenous. 

Labaraque's paste, modified by H. Zeissl, is very well 
adapted for cauterizing moist papules. Labaraque causes the 
papules to be moistened with a solution of table-salt, and after- 
ward he strews calomel over them. H. Zeissl uses diluted 



SYPHILIS. 385 

liquid chlorine instead of salt. The calomel, when it comes in 
contact with the chlorine, is probably converted into corrosive 
sublimate, and this sublimate in statu nascenti causes the warty 
growths to shrink almost painlessly, while a concentrated solu- 
tion of corrosive sublimate that will serve the purpose of de- 
stroying the adventitious growths occasions the most violent 
pains. 

Sublimate collodion is another caustic used for the pur- 
pose of removing papillary infiltration and proliferations, and 
is prepared in the following manner : 

5 Sublimat. corro?., 1*50 [grs. xxij] ; 
Collodii, 20 00 [ § as., 3 iv]. 
M. S. For external use. 

This preparation is carefully applied to the parts with a 
camel's-hair brush daily, or every other day, and afterward 
they are covered with wadding or charpie. If severe inflam- 
mation ensues, cold-water compresses should be applied. Ow- 
ing to the intense pains which this caustic preparation occa- 
sions, we only use it in places where the epidermis is very 
thick. 

We use local applications in addition to general remedies 
only in those forms of psoriasis palmaris et plantaris in which 
numerous deep fissures and epidermal welts develop in the palms 
of the hands and soles of the feet, accompanied by intense 
onychia. In mild cases we simply prescribe an ointment of 
fat and spermaceti, or unguentum diachylon in oleo-coctum, 
or paint the palms and soles with a lotion containing tar, and 
then dust the parts with powder, or apply emplastrum hy- 
drargyri to the diseased places ; or, lastly, we use white pre- 
cipitate ointment, 4-00 [3j] to 35*00 [5j, 3 iv] of cerate, 
of which the patient may rub a piece as big as a hazel-nut 
upon the palm of the hand and sole of the foot. Painting the 
affected parts with sublimate collodion or tincture of iodine 
also promotes desquamation and absorption. 

Ulcers originating as a result of paronychia should be cov- 
ered with adhesive plaster, mercurial plaster, or traumaticin. 

Deep ulcers of the skin should be cleansed as often as pos- 
sible, and then covered with emplastrum de Yigo or sapona- 
25 



386 PATHOLOGY AND TREATMENT OF SYPHILIS. 

turn. If cicatrization does not ensue, the ulcers should be 
covered with pledgets of lint smeared with the following 
ointment : 

5 Argent, nitratis cryst., 0*10 [gr. 1-J] ; 
Ung. simpl., 10-00 [ 3 lj, ^ ij] ; 
Bals. Peruv., 1*00 [grs. xvj]. 
M. Ft. ung. 

Iodoform, too, has rendered excellent service in torpid and 
proliferating ulcers. 

If suppurating gummata are situated upon the soft palate, 
and if the latter is in danger of perforation, the margins of 
the ulcer should be touched with lunar caustic every day. 
If general treatment is simultaneously instituted, small per- 
forations of the palate will often become smaller, so that it is 
barely possible to put a fine probe through them — a matter 
that is of great importance in phonation. The perforations of 
the mucous membrane on the hard palate may likewise be re- 
duced in size by the use of nitrate of silver. 

The local treatment of ozsena syphilitica has for its object 
the speedy exfoliation of the necrotic piece of nasal bone. 
This is best promoted by injecting dilute solutions of muriatic 
acid or chloride of calcium into the nasal cavities. In these 
cases we prescribe : 

^ Acidi mur. dil., 5-00 [3 iv] ; 

Aqua destil., 300*00 [ § ixss., 3 iv] ; 
Aqua salvise, 100*00 [§iij, Bviij], 
M. S. For external use. 

3 Ohlor. calcis, 5*00 [3 iv] ; 

Aqua destil., 300-00 [3 ixss., 3 iv] ; 
Aqua rosarura, 15-00 [ ^ ss.]. 
M. To be put in a black bottle for external use. 

The nasal cavities should be injected with either of these 
solutions four or five times every day by means of a syringe 
provided with a long nozzle ; or, if a fountain-syringe is used, 
the tube is inserted into the nose, the patient being directed 
to hold his head backward for a few moments, when some of 
the fluid will flow into the nasal passages. 

OzcBna syphilitica frequently is the residuum of syphilis 



SYPHILIS. 387 

that has already reached its end, the prolonged ulceration of 
the nasal bones and nasal mncoiis membrane, and the ichor- 
ous discharge, being kept up by the irritation which the ne- 
crosis of the bone exercises upon the surrounding structures. 
General treatment is only indicated in ozsena when new syphi- 
litic outbreaks occur on different parts of the body, or if those 
that already exist do not disappear. In these cases reliable 
proof of the specific character of the lesion will be necessary 
before treatment with mercury or iodine is resorted to. In 
most ozsena patients scrofula will be found to play a great 
part, and they will require cod-liver oil and tonics more than 
anti- specific remedies. 

In syphilitic sarcocele Fricke's compression-bandage may be 
employed in addition to internal general treatment, or the af- 
fected half of the scrotum may be covered with mercurial 
plaster. The coexisting hydrocele disappears spontaneously 
when the swelling of the testis has subsided ; if not, the drop- 
sical tumor may be tapped, and a dilute solution of iodine in- 
jected, or the operation for the radical cure may be performed. 

In pains of the bones and joints, which sometimes do not 
yield to either mercurial or iodine treatment, nor are assuaged 
by narcotics, we found in many cases the local treatment rec- 
ommended by Ricord to be of great benefit. He recom- 
mends a blister to be applied upon the painful part, and 
after the skin has been removed the place is either covered 
with cerate-plaster, or morphine is strewed upon the raw sur- 
face. 

Li periosteal thickenings an attempt should be made to 
bring about resolution by painting the part with tincture of 
iodine or moderately concentrated iodo-glycerine. Even if 
fluctuation is detected, the swelling should not be hastily 
opened, for absorption may sometimes take place. Should the 
pain, however, become aggravated, and the tumor larger, it 
should be opened by a valvular incision, in order to prevent 
the entrance of air into the cavity of the abscess. In very 
intense, painful periosteal swellings, Ricord and other physi- 
cians recommend deep crucial incisions and scarifications of 
the bone. 

Ulcers of the rectum should be washed several times a day, 



388 PATHOLOGY AND TREATMENT OF SYPHILIS. 

especially after each stool, and a tolerably strong solution of 
iodo-glycerine applied four or five times a day, or they may be 
cauterized with nitrate of silver. Id case stricture of the rec- 
tum is apprehended, in consequence of contracting cicatrices, 
compressed sponge-tents or cones of laminaria digitata should 
be inserted early into the gut. If stricture has already formed, 
an attempt should be made to dilate the rectum by the aid 
of bougies ; unfortunately, the results of this treatment usually 
are only temporary. There is no other therapeutic resource 
in such cases than to promote evacuations from the bowels by 
the administration of oleaginous clysters and purgative reme- 
dies. 

The Nursing of the Syphilitic Child and the Treatment of Con- 
genital Syphilis. 

So long as no evidences of syphilis are observed on a child 
begotten by syphilitic parents, it should not be subjected to 
antisyphilitic treatment, though it requires careful attention. 
The question arises, How should a child be nursed that is born 
with manifest evidences of syphilis, or that is suspected of 
being afflicted with hereditary syphilis? Should it be suckled 
by its mother, or by a wet-nurse ? That the milk of a healthy 
wet-nurse is the best nutriment for such an unfortunate creat- 
ure admits of no question. If the mother was affected with 
constitutional syphilis during pregnancy, and yet gave birth to 
a child free from all evidences of general syphilis, as is often 
the case, such a child, if possible, should be suckled by a 
healthy wet-nurse. Even admitting that the mother's milk 
does not serve as a vehicle for conveying the syphilitic virus, 
and although no morbid alteration can be discovered in it 
chemically or microscopically, still it can not be deemed 
healthy nutriment, coming as it does from a diseased, feeble 
constitution. 

But, if the mother and child are manifestly affected with 
syphilis, it will be absolutely necessary to procure a healthy 
wet-nurse for the child, because the debilitated mother will be- 
come still more enfeebled by nursing, and the infant will not 
thrive upon the unhealthy milk. But such a child should 
only be given to another woman after she has been fully in- 



SYPHILIS. 389 

formed of the risk she runs of being infected. To hide the 
true nature of the child's illness, to persuade a healthy woman 
to undertake the nursing of a syphilitic child, would be an 
unpardonable act, because the health of the woman is thereby 
endangered, while the saving of the child is doubtful; in- 
deed, in our opinion, highly improbable. However, if after 
the woman was fully informed she is disposed to undertake 
the duties of a wet-nurse, she should be instructed to keep 
herself and child scrupulously clean. On discovering any 
fissure on a nipple, she should not put the child to the affected 
breast, but nurse it on the sound breast only. She should 
not allow the child, as is customary with wet-nurses, to he at 
her breast by the hour, for then the nipples, being in contact 
with the lips of the diseased child, are sure to become injured. 
Both the nipple and breast should be washed clean every time 
the baby has been suckled. A sure protection for the wet- 
nurse is the use of a nipple-shield during the suckling of the 
infant. 

If the mother displays no evidences of constitutional syphi- 
lis, it will be far more judicious for her to wet-nurse her own 
child. So far, only three instances are known in which syphi- 
litic children infected their own mothers. The circumstance 
that mothers are never, or hardly ever, infected during wet- 
nursing by their hereditary syphilitic offspring, is now known 
by the name of Colles's law. 

Still, since it may happen that a perfectly healthy mother 
may become infected by her own syphilitic infant, it will be 
well, as Behrend suggests, to allow her to wet-nurse her child 
only so long as no evidences of syphilitic manifestations are 
observed on the mouth and fauces of the nursling. As soon 
as any specific symptoms appear on the infant, and the mother 
remains apparently well, she should be advised to discontinue 
w r et-nursing it, and bring it up on artificial food. 

If no wet-nurse can be procured to suckle such a child, and 
if the mother is not very much reduced by the syphilitic diathe- 
sis, she, being put simultaneously with the infant upon an 
antisyphilitic treatment, may be allowed to put it to her breast. 
But if the mother already shows evidences of the syphilitic 
dyscrasia, it will be preferable to bring up the child artificially 



390 PATHOLOGY AND TREATMENT OF SYPHILIS. 

upon good, fresh cow's milk, or the milk of a wet-nurse, ob- 
tained by a nursing-tube. 

In the treatment of syphilitic infants and nurslings, the 
care, cleanliness, and attention they will require deserve special 
consideration. The mouth of the nursling, especially, should 
be cleansed every time it is nursed, and, after each stool, the ex- 
coriated places at and around the anus should be washed clean 
and wiped dry. The medical treatment is both local and 
general. 

The local treatment consists in the application of slightly 
caustic remedies, such as the nitrate- of -silver stick to the ulcer- 
ating places on the lips and anus, for the purpose of hastening 
their cicatrization, of assuaging the pain during suckling and 
during evacuations from the bowels, and, above all, by the 
production of an escharotic slough to protect the ulcers on the 
mucous membrane against irritation and uncleanliness. 

For the purpose of promoting absorption of the mucous- 
membrane papules situated on the lips, angles of the mouth, 
on the anus and genital organs, and the moist papules on con- 
tiguous parts, Labaraque's paste, or a weak solution of iodo- 
glycerine, may be used. 

In regard to the general treatment, it has been suggested 
that, in view of the tender constitution of the nursling, to ad- 
minister mercurial remedies indirectly, namely, through the 
milk of the wet-nurse, who is treated with antisyphilitic medi- 
cine, or mercury is administered to goats or asses, and the 
syphilitic child is then fed with the milk from these animals. 
But numerous examinations of the milk of wet-nurses treated 
with mercury, and that of animals in whose fodder mercury 
w T as put, have shown that but very small quantities of the drug 
are found in it, and only after it had been administered to 
them for many days. 

In view of the fact that the dose of the medicine given to 
a child in this manner can not be properly controlled, as also 
the fact, often observed, that nurslings in many respects toler- 
ate mercury better than adults, we prefer the direct to the 
indirect methods. 

If no diarrhoea or other complications contraindicate it, 
calomel should be used, this preparation being best tolerated 



SYPHILIS. 391 

by infants, or the protoiodide of mercury may be prescribed , 
according to the following formula : 

3 Calomel, laevigata., or protoiod. hydrarg., 0*15 [grs. ijss.J ; 

Sacch. alba., 5-00 [3iv]. 
M. Div. in dos. aequales Xo. xij. 
M. S. One powder to be given morning and evening. 

If profuse evacuations of the bowels, with or without colic- 
pains, ensue, one drop of the tincture of opium should be given 
during the intervals. If the diarrhoea does not diminish from 
the use of this remedy, the above-named preparations should 
be discontinued, and, after the diarrhoea has been checked, 
corrosive sublimate should be resorted to, as follows : 

5 Sublim. corros., 0*005 [gr. T y] ; 
Aq. font,, 50-00 [ § jss., 9ivj. 
M. S. To be taken in one day. 

As is well known, adults not infrequently complain of gas- 
tralgia from the use of corrosive sublimate, but infants are 
troubled with vomiting. If that be the case, small inunctions 
should be ordered on some parts of the body, provided the skin 
is not profusely covered with pustules, or the body is not ex- 
tensively denuded of epidermis, or the infant is not too feeble. 
From 0*3 to 0*5 [grs. v to viij] of blue-mass may be used 
daily. The inunctions should be omitted every third day, and 
the infant placed in a tepid or warm bath. If, on account of 
numerous pustules (pemphigus syphiliticus) and excoriated 
places on the body, it is not possible to use the inunctions of 
mercury, the child should be put once or twice daily into a 
bath, containing corrosive sublimate, and prepared as follows : 

5 Sublim. corros., 2-00 to 5-00 [grs. xxxij to Ixxx] ; 

Mur. ammon., 2*00 [grs. xxxij] ; 

Aq. font., 100-00 [§iij, 3 viij]. 
M. To be added to the bath. 

The child should be kept about half an hour in this bath, 
and afterward carefully dried with warm towels. The in- 
ternal use of mercury and inunctions act much more rapidly 
than corrosive-sublimate baths. 

The preparations of iodine do not seem to agree well with 
infants ; they appear to promote marasmus in sickly children. 



392 PATHOLOGY AND TREATMENT OF SYPHILIS, 

The disappearance of the external manifestations of syphi- 
lis, however, does not by any means prove that the child has 
been cnred of the disease. But the administration of mercury 
may be suspended for a time, the child meanwhile taking the 
lactate of iron, 0-15 [grs. ijss.] twice a day. Several days aft- 
erward, the mercury may again be administered in smaller 
doses than before. Unfortunately, however, our skillfully de- 
vised cures and plans frequently miscarry, for, contrary to all 
our wishes and efforts, the little patients often succumb to the 
disease. 



INDEX. 



Abscess of lymphatic vessels and glands 

of labia majora and minora, 85. 
Acne-like syphilide, 202; differential 

diagnosis from acne vulgaris, 203. 
Acne-pustular, syphilide, 180. 
Action of chancrous virus, 109. 
Acute catarrh of the bladder, TO. 
of the larynx, syphilitic, 252. 
of the trachea, syphilitic, 252. 
Acute gonorrhoea, 13, 19. 

hydrocele, 54. 
Adenitis, multiple, 128, 131, 174. 
Affections of the bladder, 265. 

of the bones, differential diagnosis of, 

304. 
of the eye in infants in congenital 

syphilis, 328. 
of the joints, syphilitic, 305. 
of the kidney, 265. 
of the lymphatic glands in gonorrhoea, 

51. 
of the lymphatic vessels in gonor- 
rhoea, 51. 
of the lymphatic glands in the begin- 
ning of syphilis, 159. 
of the supra-renal capsule, 265. 
Age, influence of, in syphilitic disease 

of the larynx, 251. 
Air-passages, cicatrices of the, 261. 

new growths of, 263. 
Albuginitis, 265. 

Alopecia areata, 223 ; senilis, 223 ; vul- 
garis prematura, 223. 
Alteration of the blood, pathological, 
167. 
pathological, of male urethra, 25. 
Amyloid degeneration of the kidneys, 

250. 
Anatomy of the syphilitic initial sclero- 
sis, 151. 



Angina syphilitica erythematosa, 233. 

gummosa, 235. 

papulosa, 234. 
Aphthae, syphilitic, 228. 
Aura gonorrhoea, 14. 

Bacilli, syphilitic, of Lustgarten, 168. 

of Doutrelepont, 168. 
Balanitis, 46. 
Balano-blenorrhcea, 46. 
-postheitis, 46. 
-pyorrhoea, 46. 
Bartolini glands, disease of, 83 ; of the 

ducts, 83. 
Baths, mercurial, 375 ; sulphur, 380 ; 

thermal, 380. 
Black gonorrhoea, 1 3, 23. 
Bladder, diseases of the, gonorrhoeal, 69. 
acute catarrh of, 70 ; chronic catarrh, 

71; treatment of, 72, 73. 
syphilitic affections of, 265. 
Blenorrhcea, chronic, 92. 
Blood, pathological alterations of, in 

syphilis, 167. 
Bloody seminal emissions, 66. 
Bones of infants, syphilitic affections 
of, 326. 
syphilitic affections of, differential di- 
agnosis of, 304. 
syphilitic ulcers of, 302. 
Bright's disease in syphilis, 173. 
Bronchi, syphilitic affections of, 263. 

ulcers of the, 257. 
Bubo, constitutional, 131 ; idiopathic, 
131 ; deuteropathic, 131 ; proto- 
pathic, 131; resolution, 131; stru- 
mous, 137; virulent, 132. 
differential diagnosis of, 137 ; prog- 
nosis of, 137. 
site of, 135 ; shape of, 135 ; size of, 135. 



394 



INDEX. 



Bubo, treatment of the opened, 141 ; of 

the unopened, 139. 
chancroid, 132; size of, 135; shape 

of, 135. 
Bubonuli, 131. 
Bursa, syphilitic affections of, 310. 

Cachexia, the syphilitic, 170. 
Cartilages, syphilitic affections of, 30V. 
Catarrh, acute, of the bladder, 71. 
of the larynx, syphilitic, 252. 
chronic, of the bladder, VI. 
of the glans penis and prepuce, 48 ; 
differential diagnosis of, 48 ; treat- 
ment of, 48. 
irritative, 16. 

renal, course of, VV ; treatment of, VV. 
venereal, 12. 
vesical, chronic, VI. 
of vagina, epithelial, 80 ; mucous, 80 ; 
purulent, 80; serous, 80; treat- 
ment of, 82. 
vulvar, 78 ; treatment of, V9. 
chronic gonorrhoeal, 14. 
chronic, of the trachea, syphilitic, 252. 
chronic vaginal gonorrhoea, 81. 
Catarrhal nephritis, V6. 
Cauterisatio provocatoria of Tarnowski, 

171. 
Cerebral disease, syphilitic, 1V3. 
Chancre, hard, 156; duration of, 15V; 
size of, 15V ; differential diagnosis 
of, 158. 
parcheminee, Ricord, 154. 
Chancroid, 108. 
atonic, 114. 
diphtheritic, 111. 
erethetistic, 114. 
flat, 112. 
gangrenous, 114. 
phagedenic, 114. 
serpiginous, 114. 
serpigino-phagedenic, 114. 
course of, 112; differential diagnosis 

of, 118; duration of, 112. 
bubo, 132 ; shape of, 135 ; size of, 135. 
Chancrous and syphilitic virus, com- 
bined effects of, 155. 
virous action of, 109. 



Chorda venerea, 23. 

Chordee, 23. 

Chronic catarrh of the bladder, VI. 

hydrocele, 58. 
Chronic syphilitic catarrh of the larynx, 

252. 
Cirrhosis of the liver, syphilitic, 248. 
Cicatrices of the air-passages, 261. 

of the epiglottis, 262. 

of the larynx, 261. 

of the trachea, 262. 
Cold water in the treatment of syphilis, 

380. 
Co-effects of gonorrhoea in men, 29. 
Color, peculiar, of syphilitic eruptions, 

1V6. 
Combination of phases of syphilis, 1V1. 
Condyloma latum, 198. 
Condylomata, 196 ; moist, 9V ; treat- 
ment of, 100. 
Congenital syphilis, manifestations of, 
319. 

diagnosis and prognosis of, 333. 

treatment of, 388. 
Conjunctivitis granulosa, 92. 
Contagions, the venereal, 3. 
Constitutional buboes, 131. 

syphilis, 1V2; course of, 1V2. 

development of, 1V3 ; duration of, 
1V3. 

mortality in, 173. 
Construction of the scales and crusts in 

syphilis, 178. 
Corona venerea, 188. 
Corpora cavernosa penis, syphilitic af- 
fections of, 272. 
Coryza syphilitica neonatorum, 326. 
Course of constitutional syphilis, 172. 
Cowper's glands, inflammation of, 60. 
Craneotabes, 328. 

Deep syphilitic cutaneous nodes, 180. 

Definition and classification of syphilitic 
skin-diseases, 180. 

Defcedatio or scabrities unguium, 226. 

Deutropathic buboes, 131. 

Development of lymphatic glandular dis- 
ease in soft chancre, 128. 
in syphilis, 74. 



INDEX. 



395 



Diathesis, syphilitic, 166. 
Differential diagnosis of syphilis from 
erythema mercuriale, 185; from 
morbili, 1S4; pityriasis versicolor, 
185; roseola balsamica, 184; rose- 
ola typhosa, 184; rubeola, 184; 
urticaria, 184; scarlatina, 184. 
in paraphimosis and phimosis, 48. 
Disease, lcproid or syphiloid, 311. 
of the kidney caused by gonorrhoea, 
74. 
Diseases of the skin in syphilis, 175. 
syphilitic, of the fauces, 22%. 
syphilitic, of the mouth, 238. 
Duration of syphilis, 173. 

Ecthyma pustular syphilide, 180. 

Ecthyma syphiliticum, 201, 209 ; differ- 
ential diagnosis from folliculitis 
barbae, 208; from eczema rubrum, 
209 ; from ecthyma vulgar cachec- 
ticorum, 211 ; from impetiginosum, 
209 ; from sycosis, 209. 

Eczema rubrum, differential diagnosis 
from syphilitic ecthyma, 209 ; from 
confluent moist papules, 200. 

Effects of syphilitic aud chancroid virus 
combined, 155. 

Elephantiasis arabrum fuscum, 85. 
arabrum pudendum, 84. 

Elytritis papulosa, 81. 

Ephelides syphilitica, 182. 

Emissions, seminal bloody, 66. 

Endemic syphilis, 311. 

Endometritis placentaris gummosa, 317. 

Epididymis, inflammation of, 52 ; neu- 
ralgia of, 55 ; treatment of, 56. 

Epididymitis, symptoms of, 53. 

Epithelial cancer, differential diagnosis 
from chancroid, 121. 

Epithelial gonorrhoea, 13. 

Erosions of os uteri, 85. 

Erythema elevatum or papulatum, 180. 
glabrum, 54. 
maculosum, 180. 

maculo-papulatum syphiliticum neo- 
natorum, 320. 
syphiliticum membranae mucosas, 226. 

Erythematous angina, syphilitic, 233. 



Eruption, time of appearance in general 
syphilis, 169. 

Eruption, circumscribed form of, 176. 

Eruptive fever of syphilis, 168. 

Excoriations, differential diagnosis from 
chancroid, 119. 

Exhalations and transudations peculiar 
to syphilis, 179. 

Expectant method of treatment of syph- 
ilis, 342. 

External application of mercury in syph- 
ilis, 358. 

Eye, affections of, in hereditary syphilis, 
32S. 
gonorrhoea of the, 90 ; treatment of, 
92. 

Factors favoring gonorrhceal infection, 
18. 

False vocal cords, ulcers of, 257. 

Fallopian tubes, syphilitic affections of, 
270. 

Fauces, syphilitic disease of, 237, 238. 

Female, urethral gonorrhoea in, 8S. 

Fever, eruptive, of syphilis, 168. 

First period of incubation of syphilis, 
150. 

Fistula following suppurating bubo, 142 ; 
treatment of, 143. 

Flat condylomata, 196. 
papules, 196. 

Flores, or mendacea unguium, 225. 

Folliculitis barbae, differential diagnosis 
from syphilitic ecthyma, 209. 

Foci, localization of syphilitic, 169. 

French's observations on syphilitic dis- 
ease of the liver, 248. 

Functional disease of the seminal vesi- 
cle, 67. 

Functional disease of the testicle, 67. 

Galloping or malignant syphilis, 172, 

312. 
General syphilis, time of eruption of, 

169. 
Glands of Bartolini, disease of, 83 ; of 

the ducts, 83. 
Glans penis, catarrh of, 46 ; differential 

diagnosis of, 48 ; treatment of, 46. 



396 



INDEX. 



Glossitis syphilitica circumscripta super- 

ficialis, 242. 
Glossitis syphilitica diffusa, 242. 

gummatous, 238, 241, 242. 

indurativa, 238, 241, 242. 

macular, 242. 

papular, 242. . 

profunda, 242. 
Gonoccocus, Xeisser's, 15. 
Gonorrhoea, acute, 12, 13. 

black, 13, 23. 

chronic, 14. 

epithelial, 13. 

hemorrhagic, 23. 

mucous, 13. 

purulent, 13. 

Russian, 13, 23. 

serous, 13, 

site of, 17. 

uterine, 85 ; complications of, 85. 

virulent, 16. 

of female urethra, 78, 88. 

of male urethra, 19. 

co-effects of, 29. 

complications of, 83. 

pathological alterations caused by, 25. 

prognosis of, 30. 

prophylaxis against, 31. 

of mouth and nasal cavities, 90 ; of 
rectum, 89 ; treatment of, 90. 

of vulva, idiopathic, 78. 

of vulva, propagated, 78. 

of vulva, indirect, 42. 

of vulva, internal, 42. 

treatment of, 31. 

of the eye, 90 ; treatment of, 92. 

of vagina, 80 ; epithelial, 80 ; mucous, 
80; purulent, 80; serous, 80. 
Gonorrheal rheumatism, 94; treatment 

of, 96. 
Granulations of os uteri, 85. 
Gummata, 213 ; of the trachea, 254. 
Gumma of the mucous membrane, 23 1 ; 

of the larynx, 254. 
Gummatous phase of constitutional syph- 
ilis, 172. 
Gummous syphilide in the infant, 322. 

Hematocele, 59. 



Hemorrhagic syphilide in the infant, 
322. 
gonorrhoea, 23. 

Hair, syphilitic affections of, 222; dif- 
ferential diagnosis from alopecia 
senilis vulgaris prematura, 223 ; 
from herpes tondens, 223 ; from 
phyto-alopecia, 223. 

Hard chancre, treatment of, 340. 

Hereditary syphilis, 315. 

Hereditary syphilitic disease of the 
breasts, 332 ; testes, 332 ; thymus 
gland, 332. 

Hernia aquosa, 58. 
labialis, 84. 

Herpes, differential diagnosis from chan- 
croid, 118. 

Herpes tondens, 223. 

Humid or moist papules, ISO, 196. 

Hunterian induration, site of, 153 ; form 
of, 153. 

Hutchinson's syphilitic affection of the 
tongue, 244. 

Hydrocele, acute, 54 ; treatment of, 57. 
chronic, 58 ; treatment of, 59. 

Hydrops sanguinolentus, 317. 

Hypochondria mercurialis, 381. 

Hypodermic injections of mercury, 371. 

Hydrargyrosis, use of cold water and 
sulphur thermal baths in, 380. 

Idiopathic buboes, 131. 
Impetigo-pustular syphilide, 180. 

syphilitica, 206 ; differential diagnosis 
from impetigo vulgaris, 208. 
Impetiginous syphilide, 201. 
Incubation, first period of, in syphilis, 

150. 
Indirect treatment of gonorrhoea, 42. 
Induration and hypertrophy of lymphatic 
vessels and glands in syphilis, 165. 
Induration, Hunterian, 153 ; site of, 153 ; 

form of, 154. 
Infants, gummous syphilide of, 322. 
hemorrhagic syphilide in, 322. 
macular syphilides in, 320. 
syphilitic affection of the mucous mem- 
branes of, 325. 
Infantes semicocti, 317. 



INDEX. 



397 



Infants, syphilitic nursing of, 388. 
Infection, factors favoring gonorrhoea!, 

18. 
Infection, syphilitic, method of trans- 
mitting, 146. 
Infection, syphilitic, unicity of, 158. 
Infiltration of the larynx, syphilitic, 254. 

of the trachea, 254. 
Initial syphilitic lesion, differential diag- 
nosis from chancroid, 119. 
Initial multiple and strumous buboes, 

treatment of, 340. 
Influence syphilis exercises on pregnan- 
cy, 317. 
Influence syphilis exercises on mothers, 

318. 
Inflammation of the epididymis, 52. 
of Cowper's glands, 60. 
of pelvis of the kidney, 76. 
of seminal vesicles, 66. 
of vas deferens, 52. 
of glands of Bartolini, 83 ; of the 
ducts, 83 ; treatment of, 85. 
Inflammatory catarrh, purulent, 13. 

gonorrhoea, acute, 19. 
Inoculability of the sclerotic ulcer, 156. 
Internal organs, morbid alterations of, in 

hereditary syphilis, 328. 
Intestines, syphilitic diseases of, 245. 
Intestinal glands, syphilitic disease of, 

in the foetus, 331. 
Intra-uterine renal syphilis, 330. 
Introduction, 1. 
Iodine and iodine-salts, therapeutic use 

of, in syphilis, 345. 
Irritative catarrhs, 16. 
Itching of the skin in syphilis, 179. 

Joints, syphilitic affections of, 305. 

Kidneys, affections of, 265. 

amyloid degeneration in syphilis, 250. 

disease of, caused by gonorrhoea, 74. 
Klebs's observations on syphilitic disease 

of the liver, 248. 
Kolpitis, 80. 

Lacerations, differential diagnosis from 
chancroid, 119. 



La luette, vesicle of Amusset, 70. 
Larynx, syphilitic affections of, 251. 
cicatrices of, 261. 
syphilitic infiltrations of, 254. 
gumma of, 254. 
new growth in, 263. 
stenosis of, syphilitic, 173. 
ulcers in, 256. 
j La vessie a Colonne, 71. 
Lesions, morbid, of the skin in syphilis, 

175. 
Leproid or syphiloid disease, 311. 
Lenticular papule, 186, 188 ; differential 

diagnosis from lupus, 219. 
Lentigenes syphilitica, 182. 
Leucorrhoea, 81. 
Lichen scrophulosorum, resemblance of, 

to papular syphilide, 192. 
Lies, 225. 

Liver, syphilitic disease of, 247. 
Local syphilitic affections, treatment of, 

383. 
Localization of syphilitic foci, 169. 

of syphilitic eruptions, 177. 
Lungs, syphilitic affections of, 263. 
Lupus syphiliticus, exulcerativus, 218. 
hypertrophicus, 218. 
serpiginosus, 218. 

syphiliticus, differential diagnosis from 
lenticular papules, 219; from mol- 
luscum, 220; from acne rosacea 
tuberosae, 220; from rhino-sclero- 
ma, 220; from lupus vulgaris, 221 ; 
from multiple carcinoma of the 
skin, 221 ; from sarcoma and me- 
lanosis, 221. 
syphilitica hereditaria, 318. 
Lymphatic glands, affections of, in gon- 
orrhoea, 51; in syphilis, 174; in 
soft chancre, 128. 
. and vessels in gonorrhoea, 51, 128. 
of labia majora and minora, inflam- 
mation of, 85. 
Lymphatic glands, diseased, treatment 

of, 139. 
Lymphatic system of vessels, affec- 
tion of, in beginning syphilis, 159. 
Lymphatic system, induration of , 165. 
Lymphangioitis, 128. 



398 



INDEX. 



Microglossia syphilitica, 242. 

Macular glossitis, 242. 
syphilide in infants, 320. 

Markedly circumscribed form of syphi- 
litic eruptions, 175. 

Male urethra, gonorrhoea of, 19. 

Malignant syphilis, 172, 312. 

Manifestations of congenital syphilis, 
319. 

Manustupration, 14. 

Mechanism of gonorrheal infection, 1 7. 

Melanosis, differential diagnosis from 
lupus syphiliticus, 221. 

Mendacea unguium, 225. 

Mercury, external use of, in syphilis, 
358 ; inunctions of, 358 ; hypoder- 
mic injections of, 371 ; fumigations 
of, 374 ; baths of, 375 ; supposito- 
ries of, 376. 

Mercury, pathogenic effects of, 376. 
therapeutic uses of, 352. 

Mercuriophobia, 381. 

Mercurial preparations best adapted for 
introduction into the blood, 353. 

Miliary papules, 186. 

Miliary syphilides, 180, 189 ; differential 
diagnosis from scabies, 192. 

Moist or humid papules, 180, 196. 
warts, 97 ; treatment of, 100. 

Morbid lesions of the skin, 175. 

Mortality in syphilis, 172. 

Mouth and nasal cavities, gonorrhoea of, 
90. 

Mouth and nasal cavities, papular an- 
gina of, 234. 

Mouth and nasal cavities, syphilitic dis- 
ease of, 233. 

Mucous membranes of infants, syphilitic 
affections of, 325. 

Mucous membranes, syphilitic erythema 
of, 226. 

Mucous membranes of genital organs, 
syphilitic affections of, 271. 

Mucous membranes, nodes of, 231. 

Mucous gonorrhoea, 13. 

Mucous plaques, 170, 183, 203. 

Multiple adenitis, 174. 

Myer's observations on syphilitic dis- 
ease of the liver, 248. 



Nails, non-syphilitic disease of, 225. 

syphilitic disease of, 223. 
Nature of the syphilitic virus, 145. 
Neisser's gonococcus, 15. 
Nephritis, catarrhal, 76. 
New growths in larynx, 263, 

in trachea, 263. 

on vocal cords, 263. 
Nez de mouton, 230. 
Nodes of the cutis, syphilitic, 213. 

of the mucous membrane, 231. 

of the subcutaneous tissue, 213. 

of the soft palate, 235. 
Nodular syphilide of the skin, 213. 
Nursing of syphilitic children, 388. 

Occupation, influence of, in syphilitic 

disease of the larynx, 251. 
(Esophagus, syphilitic disease of, 244. 
Onychia sicca, 225. 

syphilitica, 224. 
Opened bubo, treatment of, 141. 
Ophthalmia gonorrhoica blennorrhoica, 

90. 
Orchitis syphilitica, 265. 
Ostitis syphilitica, 300. 
Os uteri, erosions of, 85. 

granulations of, 85. 
Ovaries, syphilitic disease of, 270. 
Ovula Nabothi, 86. 
Ozsena syphilitica, 318. 

Palate, node of soft, 235. 
Pancreas, syphilitic affections of, 250; 
evidences of syphilitic disease, 330. 
Papular angina of the mouth, 234. 
glossitis, 238. 
syphilide, 186, 188, 192. 
syphilide, lenticular, 188. 
syphilide in the infant, 321. 
Papules in syphilitic laryngitis, 253; 

moist, 196. 
Papules, syphilitic, of the mucous mem- 
brane, 227. 
Paraphimosis, 47 ; differential diagnosis 

of, 48 ; treatment of, 48. 
Paronychia syphilitica, 224. 
lateralis, 224. 
lunularis, 224. 



INDEX. 



Parrot's natiform skull, 328. 
Pathogenic effects of mercury, 376. 
Pathological alterations of the blood in 

syphilis, 168. 
Pathological alterations of the male 

urethra from gonorrhoea, 25. 
Pathology of the soft chancre, 110. 
Peculiar form of the syphilitic ulcer, 
178. 
color of the eruptions, 176. 
Pederasty, 89. 

Pelvis of kidney, inflammation of, 76. 
Pemphigus cachecticorum, differential 
diagnosis from pustular syphilide 
of infants, 323. 
Perichondritis syphilitica, 261. 
Period of incubation, first, in syphilis, 

150. 
Periostitis and ostitis, site and effects 

of, 303. 
Pharynx, ulcers of, 238; cicatrices of, 

262 ; new growths in, 263. 
Pharyngitis syphilitica, 238. 
Phimosis, 47 ; differential diagnosis of, 

48 ; treatment of, 48. 
Phyto-alopecia, 223. 
Pigment syphilis, 222. 
Plaques muqueuses, 170, 183, 203. 

opalines, 228. 
Pollutions, red (bloody), 66. 
Pollutio diurna, 67. 

Polymorphous form of syphilitic erup- 
tions, 178. 
Prepuce, catarrh of, 46. 
Prognosis of gonorrhoea in men, 3~>. 
Prophylaxis against gonorrhoea, 31. 

of syphilis, 337. 
Prostate, morbid alterations of, in gon- 
orrhoea, 61. 
Prostatic catarrh, glandular, 62. 
mucous, 61. 
purulent, 61, 62. 
serous, 62. 
symptoms of, 62. 
treatment of, 65. 
Prostatorrhoea, differential diagnosis 

from prostatic catarrh, 63, 67. 
Prostatorrhoea, differential diagnosis 
from spermatorrhoea, 64. 



Protopathic buboes, 131. 
Psoriasis syphilitica, 178. 

palmaris et plantaris, 180, 186, 192. 

linguae, 239. 

nigricans of Cazenave, 178. 

of the tongue, 239. 

differential diagnosis from aphthae, 
240. 
Psoriasis syphilitica of washer-women, 

196. 
Pulmonary syphilis, 264. 
Punaise, 326. 
Purulent gonorrhoea, 13. 
Pustula foetida ani, 196. 
Pustule plates, 196. 
Pustular syphilide, 201. 

in infants, 322; differential diagnosis 
from pemphigus cachecticorum, 323. 

Quantity and successive form of syphi- 
litic eruptions, 177. 

Racedo syphilitica, 233. 

Rectum, gonorrhoea of, 89 ; treatment 
of, 90. 

Relation of vaccine lymph to syphilitic 
virus, 147. 

Renal catarrh, course of, 77 ; treatment 
of, 77. 
syphilis, intra-uterine, 330. 

Rhagades, 229. 

Rheumatism, gonorrhoeal, 94 ; treatment 
of, 96. 

Ricord's division of syphilis, 171. 

Roseola syphilitica, 180. 
evanida, 182. 

Rupia syphilitica, 180, 201, 211. 

differential diagnosis from rupia vul- 
garis, 212. 

Russian gonorrhoea, 13, 23. 

Salivary glands, syphilitic affections of, 
250. 

Sarcocele syphilitica, 265. 

Sarcoma, differential diagnosis from lu- 
pus syphilitica, 221. 

Scabies pistorum, 196. 

Scabrities unguium, 226. 

Sclerotic ulcer, inoculability of, 156. 



400 



INDEX. 



Sclerosis, initial pathology of, 151. 
Sea-baths in the treatment of syphilis, 

380. 
Seborrhoea sicca congestiva, 183. 
Secondary phenomena, treatment of, 342. 
Seminal vesicles, inflammation of, 65. 

functional disease of, 67. 
Seminal emissions, bloody, 66. 
Sequelae of gonorrhoea in men, 29. 

general, 93. 
Sequelae of urethral gonorrhoea, 93. 
Serous gonorrhoea, 13. 
Sheaths of tendons, syphilitic affections 

of, 308. 
Sheep-nose, 230. 
Site and effects of periostitis and ostitis 

syphilitica, 303. 
Skin, nodular syphilide of, 213. 
Small papular syphilide, 189. 
Soft chancre, 108; atonic, 113; erethis- 
tic, 113; gangrenous, 114; phage- 
denic, 114; serpiginous, 114; ser- 
pigino-phagedenic, 114 ; develop- 
ment of, 109 ; differential diagnosis 
of, 118; pathology of, 110; site of , 
115; prognosis of, 121; treatment 
of, 121. 
Spermatic cord, inflammation of, 52 ; 
treatment of, 56. 
syphilitic affection of, 265. 
Spermatorrhoea, 67; differential diagnosis 
from prostatorrhoea, 64, 67 ; treat- 
ment of, 68. 
Spermatorrhoea cruenta, 54. 
Spitze or moist warts, 97 ; treatment of, 

100. 
Spleen, syphilitic affections of, 250. 

intra-uterine affections of, 329. 
Squamous syphilide of the hands and 

feet, 192. 
Stricture of the urethra, 101 ; inflam- 
matory, 102 ; organic, 102 ; spastic, 
102 ; treatment of, 104. 
Stomach, syphilitic disease of, 245. 
Succession and phases of syphilitic af- 
fections, 171. 
Sulphur-thermal baths in treatment of 

syphilis, 380. 
Superficial cutaneous nodes, 180. 



Suppositories, mercurial, in syphilis, 376. 
Supra-renal capsule, affections of, 265. 
Suppurating bubo, fistula of, 142 ; treat- 
ment of, 143. 
Sycosis, differential diagnosis from syphi- 
litic ecthyma, 209. 
Syphiloma, 213; Wagner's, 214; Yir- 

chow's, 214. 
Syphiliphobia, 381. 
Syphilis, 145. 
aquisita, 146. 

congenital, 319 ; manifestations of, 
319; diagnosis and prognosis of, 
333. 
endemic, 311. 

hereditary, morbid alterations of in- 
ternal organs, 328 ; hereditaria, 146. 
hereditaria tarda, 334. 
malignant or galloping, 172, 312. 
haemorrhagica, 324. 
of the cornea, 192. 
of the fauces, 233. 

constitutional, 172; course of, 173; 
development of, 172 ; duration of, 
173 ; mortality in, 173. 
combinations of, 170. 
eruptive fever of, 168. 
first period of incubation of, 150. 
influence on pregnancy, 317. 
influence on the mother, 318. 
of the mouth, 233. 
papulosa lenticularis, 180. 
papulosa miliaris, 180, 189 ; differen- 
tial diagnosis from scabies, 192; 
from psoriasis vulgaris, 191 ; from 
lichen scrophulosorum, 192; from 
herpes circinatus, 192. 
pigmentosa, 222. 
prophylaxis of, 337. 
pulmonary, 264. 
raceformis, 218. 

treatment of, 334 ; of the initial phe- 
nomena, 340 ; of the secondary 
phenomena, 342. 
treatment of local affections, 383 ; of 
congenital, 388 ; expectant meth- 
od, 342 ; medical, 345 ; by vegeta- 
ble remedies, 350 ; by inunctions of 
mercury, 358 ; by hypodermic in- 



INDEX. 



401 



jections, 371 ; by fumigations, 374 ; 
by baths, 375 ; by suppositories, 376. 

transmission of, by vaccination, 147. 

transmissibility of, 146 ; in warm- 
blooded animals, 149. 
Syphilides, 175; acne-like, 202; gum- 
mous, 322 ; hemorrhagic, 322 ; im- 
petiginous, 201 ; lenticular, 188 ; 
macular, 320 ; nodular, 213 ; papu- 
lar, 188, 189, 321 ; pustular, 201, 
322 ; squamous, 192 ; varicella- 
like, 204 ; vesicular, 201. 
Syphilitic affections, Ricord's classifica- 
tion of, 171. 

Zeissl's classification of, 171. 

of the bones in infants, 326 ; in adults, 
304 ; of the bronchi, 263 ; of the 
bursae, 310 ; of the cartilages, 307 ; 
corpora cavernosa penis, 272 ; hair, 
222 ; Fallopian tubes, 270 ; intes- 
tinal glands, 331 ; joints, 305 ; 
larynx, 251 ; lungs, 263 ; mucous 
membranes, 226 ; fauces, 237 ; of 
infants, 325; genital organs of 
both sexes, 271 ; nails, 223 ; larynx, 
251, 254; muscles, 308; pancreas, 
250; ostitis, 300; ovaries, 270; 
salivary glands, 250 ; spermatic 
cord, 265 ; spleen, 250 ; trachea, 
251 ; tongue, 244; ulcers of bones, 
302; cicatrices, 308; testicle, 332, 
265 ; uterus, 270. 

aphthae, 228. 

combinations and phases of, 171. 

erythema, 226 ; of the mouth, 238 ; 
catarrhal inflammation of, 226. 

infants, nursing of, 388. 

cirrhosis, 248. 

foci, location of, 169. 

gumma, 231. 

nodes of the cutis, 213 ; of the sub- 
cutaneous tissue, 213. 

papules of the mucous membrane, 227. 

diathesis, 165. 

disease, definitions and classification 
of, 180 ; of the fauces, 237, 238 ; in- 
testines, 245; liver, 247; mouth, 238; 
nails, 223 ; oesophagus, 244 ; skin, 
175; stomach, 245 ; tongue, 238. 
26 



glossitis, gummatous, 238, 241, 242 ; 
indurated, 238 ; macular, 242 ; pap- 
ular, 242. 
Syphilitic infection, method of trans- 
mitting it, 146. 
unicity of, 158. 
Syphilitic initial sclerosis, anatomy of, 

151. 
Syphilitic virus, nature of, 145. 
relation of, to vaccine lymph, 147. 
and chancroid virus, combined effects 
of, 155. 
Syphiliphobia, 381. 
Syphilization, 382. 

Tendons, syphilitic affections of, 308. 
Testicles, functional disease of, 67 ; treat- 
ment of, 68. 
syphilitic affections of, 265 ; heredi- 
tary, 332. 
Therapeutic use of iodides in syphilis, 

345. 
Therapeutical use of mercury, 352. 
Thymus glands, hereditary syphilis of, 

332. 
Time of general eruption of syphilis, 169. 
Tongue, syphilitic disease of, 238 ; gum- 
mata of, 242, 244 ; epithelial catarrh 
of, 241 ; Hutchinson's observations 
of, 244 ; macular, 238 ; papular, 
238. 
Trachea, cicatrices in, 262 ; gummata 
in, 254 ; infiltrations in, 254 ; new 
growths in, 263 ; papules in, 254. 
syphilitic affections of, 251. 
catarrh of, 252. 
chronic catarrh of, 252. 
ulcers of, 256. 
Trachoma, 92. 
Transmission of syphilis by vaccination, 

147. 
Treatment of catarrh of glans penis, 48. 
of gonorrhoea in men, 31 ; indirect, 

42 ; internal, 42. 
of paraphimosis, 48. 
of phimosis, 48. 

of syphilis, 334, 358 ; by mercurial 
baths, 375 ; by inunctions, 358 ; by 
fumigations, 374 ; by hypodermic 



402 



INDEX. 



injections, 371 ; with suppositories, 
376 ; of initial phenomena, 340 ; 
of Hunterian induration, 340 ; ex- 
pectant method, 342 ; medicinal, 
345 ; by vegetable remedies, 350. 
of congenital syphilis, 388. 

Tripper, 12. 

True vocal cords, ulcers of, 257. 

Tubera syphilitica, 213. 

Tubercula syphilitica, 213. 

Tarnowsky, cauterisatio provocatorio of, 
171. 

Ulcers of bones, syphilitic cicatrization 
of, 302. 
of bronchi, 257 ; of pharynx, 238 ; 
on false vocal cords, 257 ; on true 
vocal cords, 257 ; in trachea, 256 ; 
symptoms of, 260. 
Ulcer, sclerotic, inoculability of, 156. 
Ulcus elevatum, 111. 
framboesoides, 111. 
fungosum, 111. 
Unicity of syphilitic infection, 158. 
Unopened bubo, treatment of, 139. 
Urethral gonorrhoea of male, 19. 
in female, 88. 
sequelae of, 93. 
Urethritis blennorrhoica, 28. 
granulosa, 29. 
membranacea, 29. 
purulenta, 19. 
Urethra, stricture of, 102 ; inflamma- 
tory, 102 ; organic, 102 ; spastic, 
102 ; treatment of, 104. 
Uterine gonorrhoea, complications of, 85. 
Uterus, syphilitic affections of, 270. 

Vaccination, transmission of syphilis by, 
147. 

Vaccine lymph to syphilitic virus, rela- 
tion of, 147. 

Vagina, gonorrhoea of, 80 ; chronic, 81 ; 
treatment of, 82. 



Vaginitis papulosa, 81; 

Varicella syphilitica confluens neona- 
torum, 322. 
like syphilide, 204 ; differential diag- 
nosis from varicella vulgaris, 205. 
pustular syphilide, 180. 

Vas deferens, inflammation of, 52. 

Vegetations, 97. 

Venereal catarrh, 12; epithelial or mu- 
cous, 12; purulent, 12; serous, 12. 
contagions of, 3. 

Vesical catarrh, chronic, 71. 

Vesicular syphilide, 201. 

Virulent buboes, 132. 

Virus, syphilitic nature of, 145. 

Visceral syphilis, 173. 

Virchow's observation on syphilitic dis- 
ease of the liver, 247. 
on nodes, 214. 

Vocal cords, new growth of, 263. 

Vulvar catarrh, epithelial, 79 ; mucous, 
79 ; serous, 79 ; treatment of, 79. 

Vulva, gonorrhoea of, idiopathic, 78 ; 
propagated, 78 ; treatment of, 79. 

Vulvitis purulenta, 79. 

Vulgar lupus, differential diagnosis from 
lupus syphilitica, 221. 

Vulvo-vaginal gonorrhoea, complications 
of, 83. 

Wagner's syphiloma, 214. 

observation on syphilitic disease of 

the liver, 247. 
Warm-blooded animals, transmission of 

syphilis in, 149. 
Warts, moist, 97 ; treatment of, 100. 
Wetzler's observation on syphilis of the 

liver, 248. 

Xerosis vaginae, 81. 

Zeissl's classification of syphilitic affec- 
tion, 171. 



THE END, 



REASONS WHY PHYSICIANS SHOULD 
SUBSCRIBE FOR THE 

I]ew York EQedical Jourijal, 

Edited by FRANK P. FOSTER, M. D., 

Published by D. APPLETON & CO., New York. 



"DECAUSE : It is the LEADING JOURNAL of America and contains more reading- 
-^ matter than any other journal of its class. 

"DECAUSE : It is the exponent of the most advanced scientific medical thought. 

"DECAUSE : Its contributors are among the most learned medical men of this country. 

"DECAUSE : Its " Original Articles " are the results of scientific observation and re- 
search, and are of infinite practical value to the general practitioner. 

"DECAUSE : The " Reports on the Progress of Medicine," which are published from 
time to time, contain the most recent discoveries in the various departments of 
medicine, and are written by practitioners especially qualified for the purpose. 

"DECAUSE : The column devoted in each number to " Therapeutical Notes " contains a 
resume of the practical application of the most recent therapeutic novelties. 

"DECAUSE : The Society Proceedings, of which each number contains one or more, 
■^ are reports of the practical experience of prominent physicians who thus give to 
the profession the, results of certain modes of treatment in given cases. 

"DECAUSE : The Editorial Columns are controlled only by the desire to promote the 
welfare, honor, and advancement of the science of medicine, as viewed from a 
standpoint looking to the best interests of the profession. 

"DECAUSE : Nothing is admitted to its columns that has not some bearing on medicine, 
-^ or is not possessed of some practical value. 

"DECAUSE : It is published solely in the interests of medicine, and for the upholding 
■^ of the elevated position occupied by the profession of America. 



The volumes begin with January and July of each year. Subscriptions 
can be arranged to begin with the volume. 

Subscription Price, $5.00 per Annum. 

The Popular Science Monthly and the New York Medical Journal to the 
same address, $9.00 per Annum (full price, $10.00). 



New York : D. APPLETON & CO., 1, 3, & 5 Bond Street. 



THE 



POPULAR SCIENCE MONTHLY. 



CONDUCTED BY E. L. AND W. J. YOUMANS. 

The Popular Science Monthly will continue, as heretofore, to 
supply its readers with the results of the latest investigation and the 
most valuable thought in the various departments of scientific inquiry. 

Leaving the dry and technical details of science, which are of chief 
concern to specialists, to the journals devoted to them, the Monthly 
deals with those more general and practical subjects which are of the 
greatest interest and importance to the public at large. In this 
work it has achieved a foremost position, and is now the acknowl- 
edged organ of progressive scientific ideas in this country. 

The wide range of its discussions includes, among other topics : 

The bearing of science upon education ; 

Questions relating to the prevention of disease and the improve- 
ment of sanitary conditions ; 

Subjects of domestic and social economy, including the introduc- 
tion of better ways of living, and improved applications in the arts 
of every kind ; 

The phenomena and laws of the larger social organizations, with 
the new standard of ethics, based on scientific principles ; 

The subjects of personal and household hygiene, medicine, and 
architecture, as exemplified in the adaptation of public buildings 
and private houses to the wants of those who use them ; 

Agriculture and the improvement of food-products ; 

The study of man, with what appears from time to time in the 
departments of anthropology and archaeology that may throw light 
upon the development of the race from its primitive conditions. 

Whatever of real advance is made in chemistry, geography, astron- 
omy, physiology, psychology, botany, zoology, paleontology, geol- 
ogy, or such other department as may have been the field of research, 
is recorded monthly. 

Special attention is also called to the biographies, with portraits, of 
representative scientific men, in which are recorded their most marked 
achievements in science, and the general bearing of their work in- 
dicated and its value estimated. 



Terms : $5.00 per annum, in advance. 

The New York Medical Journal and The Popular Science Monthly to 
the same address, $9.00 per annum (full price, $10.00). 

D. APPLETON & CO., 1, 3, & 5 Bond Street, New York. 



%* The Books advertised in this List are commonly for sale by booksellers in 
all parts of the coimtry j but any work will be sent by D. Appleton & Co. to any 
address in the United States, postage prepaid, on receipt of the advertised price. 



CATALOGUE 

OF 

MEDICAL WORKS. 



THE PUERPERAL DISEASES. Clinical Lectures deliv- 
ered at Bellevue Hospital. By Fordyce Barker, M. D., Clinical Professor 
of Midwifery and the Diseases of Women in the Bellevue Hospital Medical 
College ; late Obstetric Physician to Bellevue Hospital ; Surgeon to the 
New York State Woman's Hospital, etc. 

Fourth edition. I vol., 8vo, 526 pp. Cloth, $5.00; sheep, $6.00. 

" For nearly twenty years it has been my duty, as well as my privilege, to give clinical lectures 
at Bellevue Hospital, on midwifery, the puerperal, and the other diseases of women. This volume. 
is made up substantially from phonographic reports of the lectures which I have given on the 
puerperal diseases. Having had rather exceptional opportunities for the study of these diseases, 
I have felt it to be an imperative duty to utilize, so far as lay in my power, the advantages which 
I have enjoyed for the promotion of science, and, I hope, for the interests ot humanity." — From 
Author's Preface. 

ON SEA-SICKNESS. By Fordyce Barker, M. D. 

1 vol., i6mo, 36 pp. Flexible cloth, 75 cents. 

Reprinted from the "New York Medical Journal." By reason of the great demand for the 
number of that Journal containing the paper, it is now presented in book form, with such prescrip- 
tions added as the author has found useful in relieving the suffering from sea-sickness. 

PARALYSIS FROM BRAIN DISEASE IN ITS COM- 
MON FORMS. By H. Charlton Bastian, M. A., M. D., Fellow of the 
Royal College of Physicians ; Professor of Pathological Anatomy in Uni- 
versity College, London. 

With Illustrations. I vol., i2mo, 340 pp. Cloth, $1.75. 

" These lectures were delivered in University College Hospital last year, at a time when I was 
doing duty for one of the senior physicians, and during the same year — after they had been repro- 
duced from very full notes taken by my friend Mr. John Tweedy — they appeared in the pages of 
' The Lancet.' They are now republished at the request of many friends, though only after having 
undergone a very careful revision, during which a considerable quantity of new matter has been 
added. It would have been easy to have very much increased the size of the book by the intro- 
duction of a larger number of illustrative cases, and by treatment of many of the subjects at greater 
length, but this the author has purposely abstained from doing under the belief that in its present 
form it is likely to prove more acceptable to students, and also perhaps more useful to busy prac- 
titioners." — Extract from Preface. 

THE MANAGEMENT OF INFANCY, Physiological and 

Moral. Intended chiefly for the Use of Parents. By Andrew Combe, M. D. 
Revised and edited by Sir James Clark, K. C. B., M. D., F. R. S., Physician- 
in-ordinary to the Queen. 

First American from the tenth London edition. I vol., i2mo, 302 pp. Cloth, $1.50. 
" This excellent little book should be in the hand of every mother of a family."— The Lancet. 



D. APPLETON &* CO.'S MEDICAL WORKS. 



ADOLPH STRECKER'S SHORT TEXT-BOOK OF OR- 
GANIC CHEMISTRY. By Dr. Johannes Wislicenus. Translated and 
edited, with Extensive Additions, by W. H. Hodgkinson, Ph. D., and A. J. 
Greenaway, F. I. C. 

8vo, 789 pp. Cloth, $5.00. 

The great popularity which Professor Wislicenus's edition of " Strecker's Text-Book of Or- 
ganic Chemistry " has enjoyed in Germany has led to the belief that an English translation will 
be acceptable. Since the publication of the book in Germany, the knowledge of organic chem- 
istry has increased, and this has necessitated many additions and alterations on the part of the 
translators. 

Specimen of Illustration. n 



"Let no one suppose 
that in this ' short text- 
book ' we have to deal with 
a primer. Everything is 
comparative, and the term 
1 short ' here has relation 
to the enormous develop- 
ment and extent of recent 
organic chemistry. This 
solid and comprehensive 
volume is intended to rep- 
resent the present condi- 
tion of the science in its 
main facts and leading 
principles, as demanded 
by the systematic chemical 
student. We have here, 
probably, the best extant 
text-book of organic chem- 
istry. Not only is it full 
and comprehensive and 
remarkably clear and me- 
thodical, but it is up to the 
very latest moment, and it 
has been, moreover, pre- 
pared in a way to secure 
the greatest excellences 
in such a treatise." — The 
Popular Science Monthly. 




PRINCIPLES OF MENTAL PHYSIOLOGY, with their 

Applications to the Training and Discipline of the Mind and the Study of 
its Morbid Conditions. By William B. Carpenter, M. D., LL. D., Reg- 
istrar of the University of London, etc. 

1 vol., 8vo, 737 pp. Cloth, $3.00. 



"Among the numerous eminent writers this 
country has produced, none are more deserving of 
praise for having attempted to apply the results of 



physiological research to the explanation of the mu- 
tual relations of the mind and body than Dr. Car- 
penter." — The Lancet. 



HEALTH. By W. H. Corfield, Professor of Hygiene and 

Public Health at University College, London. 
1 vol., i2mo. Cloth, $1.25. 



" Few persons are better qualified than Dr. Cor- 
field to write intelligently upon the subject of health, 
and it is not a matter for surprise, therefore, that he 
has given us a volume remarkable for accuracy and 
interest Commencing with general anatomy, the 
bones and muscles are given attention ; next, the 



circulation of the blood, then respiration, nutrition, 
the liver, and the execretory organs, the nervous 
system, organ's of the senses, the health of the indi- 
vidual, air, foods and drinks, drinking-water, cli- 
mate, houses and towns, small-pox, and communi- 
cable diseases." — Philadelphia Item. 



D. APPLE TON 6- CO.'S MEDICAL WORKS. 



5 



THE BRAIN AS AN ORGAN OF MIND. By H. 

Charlton Bastian, M. A., M. D., Fellow of the Royal College of Phy- 
sicians ; Professor of Pathological Anatomy in University College, London. 
With 184 Illustrations and an Index. I vol., i2mo, 708 pp. Cloth, $2.50. 



" This work is the best book of its kind. It is 
full, and at the same time concise ; comprehensive, 
but confined to a readable limit ; and, though it 
deals with many subtile subjects, it expounds them 
in a style which is admirable for its clearness and 
simplicity." — Nature. 

" The fullest scientific exposition yet published 
of the views held on the subject of psychology by 
the advanced physiological school. It teems with 
new and suggestive ideas." — London Athenceum. 



" Dr. Bastian's new book is one of great value 
and importance. The knowledge it gives is univer- 
sal in its claims, and of moment to everybody. It 
should be forthwith introduced as a manual into all 
colleges, high schools, and normal schools in the 
country ; not to be made a matter of ordinary me- 
chanical recitations, but that its subject may arrest 
attention and rouse interest, and be lodged in the 
minds of students in connection with observations 
and experiments that will give reality to the knowl- 
edge required." — Popular Science Monthly. 



TREATISE ON MATERIA MEDICA AND THERA- 

PEUTICS. Revised and enlarged. Edition of 1883, with Complete Index 
and Table of Contents. By Roberts Bartholow, M. A., M. D., LL.D., 
Professor of Materia Medica and Therapeutics in the Jefferson Medical Col- 
lege ; formerly Professor of the Theory and Practice of Medicine, and of 
Clinical Medicine, and Professor of Materia Medica and Therapeutics in 
the Medical College of Ohio, etc. 

Fifth edition, revised and enlarged. I vol., 8vo. Cloth, $5.00; sheep, $6.00. 

" The appearance of the sixth decennial revision of the ' United States Pharmacopoeia ' has 
imposed on me the necessity of preparing a new edition of this treatise. I have accordingly adapted 
the work to the official standard, and have also given to the whole of it a careful revision, incorpo- 
rating the more recent improvements in the science and art of therapeutics. Many additions have 
been made, and parts have been rewritten. These additions and changes have added about one 
hundred pages to the body of the work, and increased space has been secured in some places by 
the omission of the references. In the new material, as in the old, practical utility has been the 
ruling principle, but the scientific aspects of therapeutics have not been subordinated to a utilita- 
rian empiricism. In the new matter, as in the old, careful consideration has been given to the 
physiological action of remedies, which is regarded as the true basis of all real progress in thera- 
peutical science ; but, at the same time, I have not been unmindful of the contributions made by 
properly conducted clinical observations." — From Preface to Fifth Edition. 



" The author has adapted the present edition to 
the changes made in the sixth edition of the ' Unit- 
ed States Pharmacopoeia.' He has also given the 
whole work a careful revision, incorporating the 
more recent improvements and additions to thera- 
peutics. About one hundred pages are thus added 
to the volume. The valuable practical character of 
Dr. Bartholow's treatise has been recognized by the 
profession, and probably no one has succeeded bet- 
ter in popularizing the physiological in distinction 
from the empirical mode of studying therapeutics. 
The book is so excellent a one that we can hardly 
pick out any faults without venturing dangerously 
near hypercriticism." — Medical Record. 

" Professor Bartholow has special talent for con- 
densation, combined with a comprehensive knowl- 
edge of his subject, and a power of direct expres- 
sion. That this combination is gratefully appre- 
ciated by the overworked American student, and the 
no less overworked physician, has been fully demon- 
strated by the remarkable demand for this work on 
Therapeutics, which has now attained its fifth edi- 
tion in less than seven years. On account of its 
convenience for reference and completeness, it has 
been adopted as a text-book in many of our medi- 
cal colleges." — Philadelphia Medical Times. 

" A book which has reached its fifth edition so 



rapidly as this has done, and upon which the pro- 
fession has passed so favorable a judgment, hardly 
stands in need of a review, or of having its merits 
pointed out. It is not out of place, however, to 
note that it has been kept fully abreast of the many 
and important changes constantly making in the 
knowledge of drugs, and their application to dis- 
ease, to say nothing of hydro-, electro-, and metallo- 
therapeutics, all of which are thoroughly treated in 
this edition. . . ." — American Journal of the Med- 
ical Sciences. 

" We have lately had occasion to notice a num- 
ber of new works, and new editions of well-known 
text-books, on materia medica and therapeutics, and 
on a great proportion of them we have bestowed 
high commendation. To none, however, is greater 
praise to be awarded than to this fifth edition of 
Professor Bartholow's. The appearance of the new 
Pharmacopoeia has rendered a number of changes 
in phraseology necessary, but, in addition to those, 
the volume bears evidence throughout of having 
been brought well up to the present state of our 
knowledge. In consonance with the general voice 
of the profession, we must say that practitioners of 
medicine can scarcely afford to forego the advan- 
tages to be derived from the possession of this 
book." — New York Medical Journal. 



D. APPLETON &* CO.'S MEDICAL WORKS. 



A TREATISE ON THE PRACTICE OF MEDICINE, 

for the Use of Students and Practitioners. By Roberts Bartholow, 
M. A., M. D., LL. D., Professor of Materia Medica and General Therapeu- 
tics in the Jefferson Medical College of Philadelphia; recently Professor of 
the Practice of Medicine and of Clinical Medicine in the Medical College 
of Ohio, in Cincinnati, etc., etc. 
Fifth edition, revised and enlarged. I vol., 8vo. Cloth, $5.00; sheep or half russia, $6.00. 

The same qualities and characteristics which have rendered the author's "Treatise on Materia 
Medica and Therapeutics » so acceptable are equally manifest in this. It is clear, condensed and 
accu ate The whole work is brought up on a level with, and incorporates, the latest acquisitions 
of medical science, and may be depended on to contain the most recent information up to the date 
of publication. 



Specimen of Illustration. 










;ttr- 






:: 



" Probably the crowning feature of the work be- 
fore us and that which will make it a favorite with 
practitioners of medicine, is its admirable teaching 
on the treatment of disease. Dr. Bartholow has no 
sympathy with the modern school of therapeutical 
nihilists, but possesses a wholesome belief in the 
value and efficacy of remedies. He does not fail to 
indicate, however, that the power of remedies is 
limited, that specifics are few indeed, and that rou- 
tine and reckless medication are dangerous. But 
throughout the entire treatise in connection with 
each malady are laid down well-defined methods 
and true principles of treatment. It may be said 
with justice that this part of the work rests upon 
thoroughly scientific and practical principles of ther- 
apeutics, and is executed in a masterly manner. No 
work on the practice of medicine with which we are 
acquainted will guide the practitioner in all the de- 
tails of treatment so well as the one of which we are 
writing. "—American Practitioner. 

"The work is concise and definite in its state- 
ments, and eminently practical in its teachings. It 
is written with special reference to the needs of the 
student, and will at once take its place as a text- 
book in many medical schools. It will be found of 
equal value to the practicing physician."— Maryland 
Medical Journal. 

" The volume before us gives not only full and 
correct descriptions of diseases, but the treatment is 
enlivened under the instruction of a new therapy, 
v/hich must commend itself to every student. It is 
an honor alike to authors and the profession of the 
country."— Sout/iem Medical Record. 



"The work as a whole is peculiar, in 
that it is stamped with the individuality of 
its author. The reader is made to feel that 
the experience upon which this work is 
based is real, that the statements of the 
writer are founded on firm convictions, and 
that throughout the conclusions are emi- 
nently sound. It is not an elaborate trea- 
tise, neither is it a manual, but half-way 
between ; it may be considered a thorough- 
ly useful, trustworthy, and practical guide 
for the general practitioner." — Medical Rec- 
ord. 

' ' It may be said of so small a book on 
so large a subject, that it can be only a sort 
of compendium or vade mecum. But this 
criticism will not be just. For, while the 
author is master in the art of condensation, 
it will be found that no essential points have 
been omitted. Mention is made at least of 
every unequivocal symptom in the narra- 
tion of the signs of disease, and character- 
istic symptoms are held well up in the fore- 
ground in every case."— Cincin?iati Lancet 
and Clinic. 
" Dr. Bartholow is known to be a very clear and 
explicit writer, and in this work, which we take to 
be his special life-work, we are very sure his many 
friends and admirers will not be disappointed. We 
can not say more than this without attempting to 
follow up the details of the plan, which, of course, 
would be useless in a brief book-notice. We can 
only add that we feel confident the verdict of the 
profession wiU place Dr. Bartholow's ' Practice 
among the standard text-books of the day. — Cin- 
cinnati Obstetric Gazette. 

"It is refreshing to turn from a work so crude 
and incomplete, so full of the exploded theories of 
by-eone days, as that of Professor Palmer, to the 
clear lucid pages of Professor Bartholow. Pro- 
fessor Bartholow has won for himself so high a posi- 
tion as an original thinker and clear and forcible 
writer that any work from his pen would command 
attention and respect. One great charm of the 
writer is the intelligence and original thought which 
he brings to the discussion of every subject, and the 
directness, clearness, and vigor of his style. In his 
treatment he is much in advance of the leading 
writers of his school, and gives marked indications ot 
having studied appreciatively some of the best writers 
of the new school."— New York Medical Times. ^ 

" The book is marked by an absence of all dis- 
cussion of the latest, fine-spun theories of points in 
pathology : by the clearness with which points m 
diagnosis are stated ; by the conciseness and per- 
spicuity of its sentences ; by the abundance of the 
author's therapeutic resources ; and by the copious- 
ness of its illustrations. "-CW* Medical Recorder. 



D. APPLETON &* CO.'S. MEDICAL WORKS. » 

ON THE ANTAGONISM BETWEEN MEDICINES 

AND BETWEEN REMEDIES AND DISEASES. Being the Cart- 
wright Lectures for the Year 1880. By Roberts Bartholow, M. A., 
M. D., LL. D., Professor of Materia Medica and General Therapeutics in 
the Jefferson Medical College of Philadelphia, etc., etc. 
1 vol., 8vo. Cloth, $1.25. 

"We are glad to possess, in a form convenient no doubt that this, his latest contribution to medi- 

for reference, this most recent summary of the physi- cal science, will add materially to his previously high 

ological action of important remedies, with the de- reputation. Much profit, no little pleasure, and 

ductions of a careful and accomplished observer, re- material assistance in the solution of many thera- 

garding the applications of this knowledge to dis- peutical problems are to be obtained from a perusal 

eased states." — College and Clinical Record. of these lectures. The author has done wisely and 

"There are few writers who have taken the conferred a boon by permitting their publication in 

trouble to compile the lucubrations of the multitude * he present book-form, and we are satisfied it will 

of scribblers who find a specific in every drug they be extensively asked for, and just as extensively read 

happen to prescribe for a self-limited, non-malig- ^nd appreciated. —Canada Medical and Surgical 

nant disease , and fewer who can detect the trashy Journal. 

chaff and garner only the ripe, plump grains. This " It will be observed that the scope of the work 

Bartholow has done, and no one is more ripe, nor is extensive, and, in justice to the author, not only 

better qualified for this herculean task ; and, the is the extent of this indicated, but the character of 

best of all is, condense it all in his antagonisms. it is also furnished. No one can read the synopsis 

No one can peruse its pregnant pages without no- given without being impressed with the importance 

ticing the painstaking research and large collection and diversity of the subjects considered. Indeed, 

of authorities from which he has drawn his conclu- most of the important forces in therapeutics and 

sions. The practitioner who purchases these antag- materia medica are herein stated and analyzed " — 

onisms will find himself better qualified to cope with American Medical Bi- 11 'eekly. 

the multifarious maladies after its careful perusal." «. Probably most of our readers will consider 

—Indiana Medical Reporter. that we have awarded this treatise high praise when 

"The criticisms made upon these lectures have we say that it seems to us the most carefully writ- 

invariably been most favorable, the topic itself is ten, best thought-out, and least dogmatic work 

one of the most interesting in the entire range of which we have yet read from the pen of its author, 

medicine, and it is treated of by the accomplished It is indeed a very praiseworthy book ; not an origi- 

author in a most scholarly manner. Dr. Bartholow nal research, indeed, but, as a resume of the world's 

worthily ranks as one of the best writers, while at work upon the subject, the best that has hitherto 

the same time one of the most diligent workers, in been published in any language." — Philadelphia 

the medical field in all America, and there can be Medical Times. 

WINTER AND SPRING ON THE SHORES OF THE 

MEDITERRANEAN; or, the Genoese Rivieras, Italy, Spain, Corfu, 

Greece, the Archipelago, Constantinople, Corsica, Sicily, Sardinia, Malta, 

Algeria, Tunis, Smyrna, Asia Minor, with Biarritz and Arcachon, as Winter 

Climates. By James Henry Bennet, M. D., Member of the Royal College 

of Physicians, London, etc., etc. 

Fifth edition. With numerous Illustrations and Maps. I vol., i2mo, 655 pp. Cloth, $3.50. 

This work embodies the experience of fifteen winters and springs passed by Dr. Bennet on the 
shores of the Mediterranean, and contains much valuable information for physicians in relation to 
the health-restoring climate of the regions described. 

" We commend this book to our readers as a vol- once entertaining and instructive." — New York 
ume presenting two capital qualifications — it is at Medical Journal. 

ON THE TREATMENT OF PULMONARY CON- 

SUMPTION, by Hygiene, Climate, and Medicine, in its Connection with 
Modern Doctrines. By James Henry Bennet, M. D., Member of the 
Royal College of Physicians, London; Doctor of Medicine of the Uni- 
versity of Paris, etc., etc. 

1 vol., thin 8vo, 190 pp. Cloth, $1.50. 

An interesting and instructive work, written in the strong, clear, and lucid manner which ap- 
pears in all the contributions of Dr. Bennet to medical or general literature. 

"We cordially commend this book to the at- temperate climates, pulmonary consumption." — De* 
tention of all, for its practical, common-sense news troit Review of Medicine. 
of the nature and treatment of the scourge of all 



8 



D. APPLETON &* CO.'S MEDICAL WORKS. 



GENERAL SURGICAL PATHOLOGY AND THERA- 
PEUTICS, in Fifty-one Lectures. A Text-Book for Students and Phy- 
sicians. By Dr. Theodor Billroth, Professor of Surgery in Vienna. 
With Additions by Dr. Alexander von Winiwarter, Professor of Surgery in 
Ltittich. Translated from the fourth German edition with the special per- 
mission of the author, and revised from the tenth edition, by Charles E. 
Hackley, A. M., M. D., Physician to the New York and Trinity Hospitals; 
Member of the New York County Medical Society, etc. 
I vol., 8vo, 835 pp. Cloth, $5.00; sheep, $6.00. 




Giant-celled Sarcoma with Cysts and Ossifying Foci from the Lower Jaw. — Magnified 350 diameters. 

" Since this translation was revised from the sixth German edition in 1874, two other editions 
have been published. The present revision is made to correspond to the eighth German edition. 

" Lister's method of antiseptic treatment is referred to in various places, and other new points 
that have come up within a few years are discussed. 

"A chapter has been written on amputation and resection. In all, there are seventy -four 
additional pages, with a number of woodcuts." — Extract from Translator 's Preface to the Revised 
Edition. 

" The want of a book in the English language, ture to say no book could more perfectly supply 
presenting in a concise form the views of the Ger- that want than the present volume." — The Lan- 
man pathologists, has long been felt, and we ven- cet. 



THE PHYSIOLOGICAL AND THERAPEUTICAL 

ACTION OF ERGOT. Being the Joseph Mather Smith Prize Essay for 

1881. By Etienne Evetzky, M. D. 

I vol., 8vo. Limp cloth, $1.00. 

"In undertaking the present work my object was to present in a condensed manner all the 
therapeutic possibilities of ergot. In a task of this nature, original research is out of the ques- 
tion. No man's evidence is sufficient to establish the merits of a drug considered in the manner 
indicated, and no one man's opportunities are sufficient to grasp the entire subject. Consequently 
it remained to gather from the volumes of past and current periodical literature the testimony of 
the multitude of physicians that had been led to use ergot in different morbid conditions. I have 
recorded everything that has come to my notice, I have grouped and classified the immense mate- 
rial in our possession. In all cases in which the action of ergot could be explained, I have at- 
tempted to do so, although this task is frequently difficult, if not impossible. . . . The reader will 
see that ergot has been used in a large number of diseases ; some of these uses have little or no 
practical value, yet it is very important to know them, as they serve to illustrate the therapeutic 
properties of the drug. They have been brought to the notice of the reader without any com- 
ments, but those that are essential and of the greatest practical importance have been dealt with 
more fully. Among the latter may be mentioned the use of ergot in inflammation, aneurism, car- 
diac diseases, the post-parturient state, uterine fibroid tumors, rheumatism, etc." — From Preface. 



D. APPLETON &> CO.'S MEDICAL WORKS. g 

OBSTETRIC CLINIC. A Practical Contribution to the Study 

of Obstetrics, and the Diseases of Women and Children. By George T. 

Elliot, M. D., late Professor of Obstetrics and Diseases of Women and 

Children in the Bellevue Hospital Medical College ; Physician to Bellevue 

Hospital and to the New York 'Lying-in Asylum, etc. 

i vol., 8vo, 458 pp. Cloth, $4.50. 

This work is, in a measure, a resume 'of separate papers previously prepared by the late Dr. 
Elliot; and contains, besides, a record of nearly two hundred important and difficult cases in mid- 
wifery, selected from his own practice. The cases thus collected represent faithfully the diffi- 
culties, anxieties, and disappointments inseparable from the practice of obstetrics, as well as some 
of the successes for which the profession are entitled to hope in these arduous and responsible 
tasks. It has met with a hearty reception, and has received the highest encomiums both in this 
country and in Europe. 

THE SOURCE OF MUSCULAR POWER. Arguments 

and Conclusions drawn from Observations upon the Human Subject under 
conditions of Rest and of Muscular Exercise. By Austin Flint, Jr., M. D., 
Professor of Physiology in the Bellevue Hospital Medical College, New- 
York, etc., etc. 

1 vol., 8vo, 103 pp. Cloth, $1.00. 

"There are few questions relating to Philosophy of greater interest and importance than the 
one which is the subject of this essay. I have attempted to present an accurate statement of my 
own observations and what seem to me to be the logical conclusions to be drawn from them, as 
well as from experiments made by others upon the human subject under conditions of rest and of 
muscular exercise." — From the Preface. 

ON THE PHYSIOLOGICAL EFFECTS OF SEVERE 

AND PROTRACTED MUSCULAR EXERCISE. With special ref- 
erence to its Influence upon the Excretion of Nitrogen. By Austin Flint, 
Jr., M. D., Professor of Physiology in the Bellevue Hospital Medical Col- 
lege, New York, etc., etc. 

1 vol., 8vo, 91 pp. Cloth, $1.00. 

This monograph on the relations of Urea to Exercise is the result of a thorough and careful 
investigation made in the case of Mr. Edward Payson Weston, the celebrated pedestrian. The 
chemical analyses were made under the direction of R. O. Doremus, M. D., Professor of Chem- 
istry and Toxicology in the Bellevue Hospital Medical College, by Mr. Oscar Loew, his assistant. 
The observations were made with the co-operation of J. C. Dalton, M. D., Professor of Physiol- 
ogy in the College of Physicians and Surgeons; Alexander B. Mott, M. D., Professor of Surgical 
Anatomy; W. H. Van Buren, M. D., Professor of Principles of Surgery; Austin Flint, M. D., 
Professor of the Principles and Practice of Medicine; W. A. Hammond, M. D., Professor of the 
Diseases of the Mind and Nervous System — all of the Bellevue Hospital Medical College. 

MANUAL OF CHEMICAL EXAMINATION OF THE 

URINE IN DISEASE. With Brief Directions for the Examination of 

the most Common Varieties of Urinary Calculi. By Austin Flint, Jr., 

M. D., Professor of Physiology and Microscopy in the Bellevue Hospital 

Medical College ; Fellow of the New York Academy of Medicine, etc. 

Fifth edition, revised and corrected. I vol., i2mo, 77 pp. Cloth, $1.00. 

The chief aim of this little work is to enable the busy practitioner to make for himself, rapidly 
and easily, all ordinary examinations of Urine; to give him the benefit of the author's experience 
in eliminating little difficulties in the manipulations, and in reducing processes of analysis to the 
utmost simplicity that is consistent with accuracy. 

" We do not know of any work in English so reputation of the author is a sufficient guarantee of 
complete and handy as the Manual now offered to the accuracy of all the directions given."— Journal 
the Profession by Dr. Flint, and the high scientific of Applied Chemistry. 



IO 



D. APPLETON &* CO.'S MEDICAL WORKS. 



TEXT-BOOK OF HUMAN PHYSIOLOGY, for the Use 

of Students and Practitioners of Medicine. By Austin Flint, Jr., M. D., 
Professor of Physiology and Physiological Anatomy in the Bellevue Hospital 
Medical College, New York ; Fellow of the New York Academy of Medi- 
cine, etc. 
Third edition. Revised and corrected. In one large 8vo volume of 978 pp., elegantly printed on 

fine paper, and profusely illustrated with three Lithographic Plates and 315 Engravings on 

Wood* Cloth, $6.00; sheep, $7.00. 




Stomach, Pancreas, Large Intestine, etc. 

" The author of this work takes rank among the 
very foremost physiologists of the day, and the care 
which he has bestowed in bringing this third edition 
of his text -book up to the present position of his 
science is exhibited in every chapter. " — Medical and 
Surgical Reporter {Philadelphia). 

"In the amount, of matter that it contains, in 
the aptness and beauty of its illustrations, in the 
variety of experiments described, in the complete- 
ness with which it discusses the whole field of human 
physiology, this work surpasses any text-book in 
the English language." — Detroit Lancet. 

" The student and the practitioner, whose sound 
practice must be based on an intelligent appreciation 
of the principles of physiology, will herein find all sub- 
jects in which they are interested fully discussed and 
thoroughly elaborated." — College and Clin. Record. 

"We have not the slightest intention of criticis- 
ing the work before us. The medical profession 
and colleges have taken that prerogative out of the 



Longitudinal Section of the Human Larynx, 
^showing the Vocal Cords. 



hands of the journalists by adopting it as one of 
their standard text-books. The work has very few 
equals and no superior in our language, and every- 
body knows it." — Hahnemannian Monthly. 

" We need only say that in this third edition the 
work has been carefully and thoroughly revised. It 
is one of our standard text -books, and no physician's 
library should be without it. We treasure it highly, 
shall give it a choice, snug, and prominent position 
on our shelf, and deem ourselves fortunate to pos- 
sess this elegant, comprehensive, and authoritative 
work." — American Specialist. 

" Professor Flint is one of the most practical 
teachers of physiology in this country, and his book 
is eminently like the man. It is very full and com- 
plete, containing practically all the established facts 
relating to the different subjects. This edition con- 
tains a iiumber of important additions and changes, 
besides numerous corrections of slight typographical 
and other errors." — Ohio Medical Recorder. 



D. APPLETON &» CO.'S MEDICAL WORKS. 



II 



THE PHYSIOLOGY OF MAN. Designed to represent the 

Existing State of Physiological Science as applied to the Functions of the 
Human Body. By Austin Flint, Jr., M. D., Professor of Physiology and 
Physiological Anatomy in the Bellevue Hospital Medical College, New 
York; Fellow of the New York Academy of Medicine, etc., etc. 
New and thoroughly revised edition. In 5 vols., 8vo. Per volume, cloth, $4.50; sheep, $5.50. 

Volume I. The Blood ; Circulation ; Respiration. 

Volume II. Alimentation ; Digestion ; Absorption ; Lymph and Chyle. 

Volume III. Secretion; Excretion; Ductless Glands; Nutrition; /.nimal 

Heat ; Movements ; Voice and Speech. 
Volume IV. The Nervous System. 
Volume V. Special Senses ; Generation. 



"As a book of general information it will be 
found useful to the practitioner, and, as a book of 
reference, invaluable in the hands of the anatomist 
and physiologist." — Dublin Quarterly Journal of 
Medical Science. 

" Dr. Flint's reputation is sufficient to give a 
character to the book among the profession, where 
it will chiefly circulate, and many of the facts given 



have been verified by the author in his laboratory 
and in public demonstration." — Chicago Courier. 

" The author bestows judicious care and labor. 
Facts are selected with discrimination, theories crit- 
ically examined, and conclusions enunciated with 
commendable clearness and precision." — A?nerican 
Journal 0/ the Medical Sciences. 



SYPHILIS AND MARRIAGE. Lectures delivered at the 

St. Louis Hospital, Paris. By Alfred Fournier, Professeur a la Faculte 
de Medecine de Paris; Medecin de l'Hopital Saint-Louis. Translated by 
P. Albert Morrow, M. D., Physician to the Skin and Venereal Department, 
New York Dispensary, etc., etc. 

1 vol., 8vo. Cloth, $2.00; sheep, $3.00. 



" The book supplies a want long recognized in 
medical literature, and is based upon a very ex- 
tended experience in the special hospitals for syphilis 
of Paris, which have furnished the author with a rich 
and rare store of clinical cases, utilized by him with 
great discrimination, originality, and clinical judg- 
ment. It exhibits a profound knowledge of its sub- 
ject under all relations, united with marked skill and 
tact in treating the delicate social questions neces- 
sarily involved in such a line of investigation. The 
entire volume is full of information, mnemonically 
condensed into axiomatic 'points.' It is a book to 
buy, to keep, to read, to profit by, and to lend to 
others." — Boston Medical and Surgical Journal. 

" This work of the able and distinguished French 
syphilographer, Professor Fournier, is without doubt 
one of the most remarkable and important produc- 
tions of the day. Possessing profound knowledge 
of syphilis in all its protean forms, an unexcelled 
experience, a dramatic force of expression, untinged, 
however, by even a suspicion of exaggeration, and 
a rare tact in dealing with the most delicate prob- 
lems, he has given to the world a series of lectures 
which, by their fascination of style, compels atten- 
tion, and by their profundity of wisdom carries con- 
viction." — St. Louis Courier of Medicine and Col- 
lateral Sciences. 

"Written with a perfect fairness, with a supe- 
rior ability, and in a style which, without aiming at 
effect, engages, interests, persuades, this work is one 
of those which ought to be immediately placed in 
the hands of every physician who desires not only 
to cure his patients, but to understand and fulfill his 
duty as an honest man." — Lyon Medicate. 

" No physician, who pretends to keep himself 



informed upon the grave social questions to which 
this disease imparts an absorbing interest, can afford 
to leave this valuable work unread." — St. Louis 
Clinical Record. 

" The author handles this grave social problem 
without stint. A general perusal of this work would 
be of untold benefit to society." — Louisville Medical 
News. 

" The subject is treated by Professor Fournier in 
a manner that is above criticism. Exhaustive clini- 
cal knowledge, discriminating judgment, and thor- 
ough honesty of opinion are united in the author, 
and he presents his subject in a crisp and almost 
dramatic style, so that it is a positive pleasure to 
read the book, apart from the absolute importance 
of the question of which it treats." — New York 
Medical Record. 

" Every page is full of the most practical and 
plain advice, couched in vigorous, emphatic lan- 
guage." — Detroit Lancet. 

" The subject here presented is one of the most 
important that can engage the attention of the pro- 
fession. The volume should be generally read, as 
the subject-matter is of great importance to society." 
— Maryland Medical Journal. 

"We can give only a very incomplete idea of 
this work of M. Fournier, which, by its precision, 
its clearness, by the forcible manner in which the 
facts are grouped and presented, defies all analysis. 
' Syphilis and Marriage ' ought to be read by all 
physicians, who will find in it, first of all, science, 
but who will also find in it, during the hours they 
devote to its perusal, a charming literary pleasure." 
— Annates de Dermatologie et de Syphiligraphie. 



12 



D. APPLETON 6- CO.'S MEDICAL WORKS. 



CYCLOPEDIA OF PRACTICAL RECEIPTS, and XDol- 

lateral Information in the Arts, Manufactures, Professions, and Trades, 
including Medicine, Pharmacy, and Domestic Economy. Designed as a 
Comprehensive Supplement to the Pharmacopoeia, and General Book of 
Reference for the Manufacturer, Tradesman, Amateur, and Heads of Fam- 
ilies. Sixth edition, revised and partly rewritten by Richard V. Tuson, 
Professor of Chemistry and Toxicology in the Royal Veterinary College. 
Complete in 2 vols., 1,796 pp. With Illustrations. Cloth, $9.00. 

Cooley's "Cyclopaedia of Practical Receipts " has for many years enjoyed an extended reputa- 
tion for its accuracy and comprehensiveness. The sixth edition, now just completed, is larger 
than the last by some six hundred pages. Much greater space than hitherto is devoted to Hygiene 
(including sanitation, the composition and adulteration of foods), as well as to the Arts, Phar- 
macy, Manufacturing Chemistry, and other subjects of importance to those for whom the work is 
intended. The articles on what is commonly termed "Household Medicine" have been ampli- 
fied and numerically increased. 

The design of this work is briefly but not completely expressed in its title-page. Independ- 
ently of a reliable and comprehensive collection of formulae and processes in neaidy all the indus- 
trial and useful arts, it contains a description of the leading properties and applications of the 
substances referred to, together with ample directions, hints, data, and allied information, cal- 
culated to facilitate the development of the practical value of the book in the shop, the laboratory, 
the factory, and the household. Notices of the substances embraced in the Materia Medica, in 
addition to the whole of their preparations, and numerous other animal and vegetable substances 
employed in medicine, as well as most of those used for food, clothing, and fuel, with their eco- 
nomic applications, have been included in the work. The synonyms and references are other addi- 
tions which will prove invaluable to the reader. Lastly, there have been appended to all the 
principal articles referred to brief but clear directions for determining their purity and commercial 
value, and for detecting their presence and proportions in compounds. The indiscriminate adop- 
tion of matter, without examination, has been uniformly avoided, and in no instance has any form- 
ula or process been admitted into this work, unless it rested on some well-known fact of science, 
had been sanctioned by usage, or come recommended by some respectable authority. 

THE COMPARATIVE ANATOMY OF THE DOMES- 
TICATED ANIMALS. By A. Chauveau, Professor at the Lyons Vet- 
erinary School. Second edition, revised and enlarged, with the co-operation 
of S. Arloing, late Principal of Anatomy at the Lyons Veterinary School ; 
Professor at the Toulouse Veterinary School. Translated and edited by 
George Fleming, F. R. G. S., M. A. L, Veterinary Surgeon, Royal Engineers, 
vol., 8vo, 957 pp. With 450 Illustrations. Cloth, $6.00. 

Specimen of Illustration. 




"Taking it altogether, the book is a very wel- 
come addition to English literature, and great credit 
is due to Mr. Fleming for the excellence of the trans- 
lation, and the many additional notes he has ap- 
pended to Chauveau's treatise." — Lancet {London). 

" The descriptions of the text are illustrated and 



assisted by no less than 450 excellent woodcuts. In 
a work which ranges over so vast a field of anatomi- 
cal detail and description, it is difficult to select any 
one portion for review, but our examination of it 
enables us to speak in high terms of its general ex- 
cellence. . . ." — Medical Times and Gazette {Lon- 
don). 



D. APPLETON 6- CO.'S MEDICAL WORKS. 



13 



THE HISTOLOGY AND HISTO-CHEMISTRY OF 

MAN. A Practical Treatise on the Elements of Composition and Struc- 
ture of the Human Body. By Heinrich Frey, Professor of Medicine in 
Zurich. Translated from the fourth German edition, by Arthur E. J. Bar- 
ker, Surgeon to the City of Dublin Hospital ; Demonstrator of Anatomy, 
Royal College of Surgeons, Ireland ; and revised by the Author. With 680 
Engravings. 

683 pp. Cloth, $5 ; sheep, $6. 



vol. 



>vo. 



CONTEXTS.— The Elements 
of Composition and of Structure 
of the Body : Elements of Com- 
position — Albuminous or Protein 
Compounds, Haemoglobulin, His- 
togenic Derivatives of the Albu- 
minous Substances or Albumi- 
noids, the Eatty Acids and Fats, 
the Carbo-hydrates, Non-Nitro- 
genous Acids, Nitrogenous Acids, 
Amides, Amido-Acids, and Or- 
ganic Bases, Animal Coloring 
Matters, Cyanogen Compounds, 
Mineral Constituents ; Elements 
of Structure — the Cell, the Origin C| 
of the Remaining Elements of 1& 
Tissue ; the Tissues of the Body 
— Tissues composed of Simple 
Cells, with Fluid Intermediate 
Substance, Tissues composed of 
Simple Cells, with a small amount 
of Solid Intermediate Substance, 
Tissues belonging to the Con- 
nective Substance Group, Tissues 
composed of Transformed and, 
as a rule, Cohering Cells, with 
Homogeneous, Scanty, and more or less Solid Intermediate Substance ; Composite Tissues : The 
Organs of the Body — Organs of the Vegetative Type, Organs of the Animal Group. 




Transverse Section 01 a Human Bone. 



CONSERVATIVE SURGERY, as exhibited in remedying 
some of the Mechanical Causes that operate injuriously both in Health and 
Disease. With Illustrations. By Hexry G. Davis, M. D., Member of the 
American Medical Association, etc., etc. 

1 vol., 8vo, 315 pp. Cloth, $3. 

The author has enjoyed rare facilities for the study and treatment of certain classes of disease, 
and the records here presented to the profession are the gradual accumulation of over thirty years' 
investigation. 

" Dr. Davis, bringing as he does to his specialty deem it worthy of a place in every physician's li- 

a great aptitude for the solution of mechanical prob- brary. The style is unpretending, but trenchant, 

lems, takes a high rank as an orthopedic surgeon, graphic, and, best of all, quite intelligible." — Medi- 

and his very practical contribution to the literature cal Record. 
of the subject is both valuable and opportune. We 



YELLOW FEVER A NAUTICAL DISEASE. Its 

Origin and Prevention. By John Gamgee. 

1 vol., 8vo, 207 pp. Cloth, $1.50. 

The theory is certainly shown to be a plausible 



" The author discusses, with a vast array of clear 
and well-digested facts, the nature and prevention 
of yellow fever. The work is admirably written, 
and the author's theories plausible and well sus- 
tained by logical deductions from established facts." 
— Homoeopathic Times. 



one ; and every reader, whether he be convinced or 
not, can not but be interested, instructed, and set to 
thinking." — Lancet and Clinic. 



H 



D. APPLETON &* CO.'S MEDICAL WORKS. 



Specimen of Illustration. 



CONTRIBUTIONS TO REPARATIVE SURGERY, show- 
ing its Application to the Treatment of Deformities, produced by Destruc- 
tive Disease or Injury; Congenital Defects from Arrest or Excess of Devel- 
opment ; and Cicatricial Contractions following Burns. Illustrated by Thirty 
Cases and fine Engravings. By Gurdon Buck, M. D. 
i vol., 8vo, 237 pp. Cloth, $3. 

" There is no department of surgery where the ingenuity 
and skill of the surgeon are more severely taxed than when 
required to repair the damage sustained by the loss of parts, 
or to remove the disfigurement produced by destructive dis- 
ease or violence, or to remedy the deformities of congenital 
malformation. The results obtained in such cases within 
the last half-century are among the most satisfactory achieve- 
ments of modern surgery. The term * Reparative Surgery ' 
chosen as the title of this volume, though it may, in a com- 
prehensive sense, be applied to the treatment of a great 
variety of lesions to which the body is liable, is, however, 
restricted in this work exclusively to what has fallen under 
the author's own observation, and has been subjected to the 
test of experience in his own practice. It largely embraces 
the treatment of lesions of the face, a region in which plastic 
surgery finds its most frequent and important applications. 
Another and no less important class of lesions will also be 
found to have occupied a large share of the author's atten- 
tion, viz., cicatricial contractions following burns. While 
these cases have a very strong claim upon our commisera- 
tion, and should stimulate us, as surgeons, to the greatest 
efforts for their relief, they have too often in the past been 
dismissed as hopelessly incurable. The satisfactory results 
obtained in the cases reported in this volume will encour- 
age other surgeons, we trust, to resort with greater hope- 
fulness in the future to operative interference. Accuracy 
of description and clearness of statement have been aimed 
at in the following pages; and if, in his endeavor to attain 
this important end, the author has incurred the reproach of 
tediousness, the difficulty of the task must be his apology." 
— Extract from Preface. 




THE CHEMISTRY OF COMMON LIFE. Illustrated 

with numerous Wood Engravings. By the late James F. W. Johnson, 
F. R. S., Professor of Chemistry in the University of Durham. A new 
edition, revised and brought down to the Present Time. By Arthur Her- 
bert Church, M. A., Oxon. 
Illustrated with Maps and numerous Engravings on Wood. In one vol., i2mo, 592 pp. $2. 

SUMMARY OF CONTENTS.— The Air we Breathe; the Water we Drink; the Soil we 
Cultivate ; the Plant we Rear ; the Bread we Eat ; the Beef we Cook ; the Beverages we Infuse ; 
the Sweets we Extract ; the Liquors we Ferment ; the Narcotics we Indulge jn ; the Poisons we 
Select; the Odors we Enjoy; the Smells we Dislike; the Colors we Admire ; What we Breathe 
and Breathe for ; What, How, and Why we Digest ; the Body we Cherish ; the Circulation of 
Matter. 



THE TONIC TREATMENT OF SYPHILIS. By E. L. 

Keyes, A. M., M. D., Adjunct Professor of Surgery and Professor of Der- 
matology in the Bellevue Hospital Medical College, etc. 
1 vol., 8vo, 83 pp. Cloth, $1. 

" My studies in syphilitic blood have yielded results at once so gratifying to me, and so con- 
vincing as to the tonic influence of minute doses of mercury, that I feel impelled to lay this brief 
treatise before the medical public in support of a continuous treatment of syphilis by small (tonic) 
doses of mercury. I believe that a general trial of the method will, in the long run, vindicate its 
excellence." — Extract from Preface. 



D. APPLETON &* CO.'S MEDICAL WORKS. 



15 



A PRACTICAL TREATISE ON TUMORS OF THE 

MAMMARY GLAND : embracing their Histology, Pathology, Diagnosis, 
and Treatment. By Samuel W. Gross, A. M., M. D., Surgeon to, and 
Lecturer on Clinical Surgery in, the Jefferson Medical College Hospits-1 
and the Philadelphia Hospital, etc. 

In one handsome 8vo vol. of 246 pp., with 29 Illustrations. Cloth, $2.50. 

"The work opportunely supplies a real want, 
and is the result of accurate work, and we heartily 
recommend it to our readers as well worthy of care- 
ful study." — Lotidon Lancet. 

" We know of no book in the English language 
which attempts to cover the ground covered by this 
one — indeed, the author seems to be the first who has 
sought to handle the whole subject of mammary 
tumors in one systematic treatise. How he has suc- 
ceeded will best be seen by a study of the book itself. 
In the early chapters the classification and relative 
frequency of the various tumors, their evolution and 
transformations, and their etiology, are dealt with ; 
then each class is studied in a separate chapter, in 
which the result of the author's work is compared 
with that of others, and the general conclusions are 
drawn which give to the book its great practical 
value ; finally, a chapter is devoted to diagnosis, one 
to treatment, and one to the tumors in the mam- 
mary gland of the male." — New York Medical 
Journal. 

"We heartily commend this work to the profes- 
sion, knowing that those who study its pages will 
be well repaid and have a better understanding of 
what to the average practitioner is obscure and un- 
satisfactory." — l^oledo Medical and Surgical Jour- 
nal. 

" Dr. Gross has produced a work of real and 
permanent value ; it is not overstating the truth to 
say that this little volume is probably the best con- 
tribution to medical science which the present year 
has brought forth. We believe that the author has 





Development ot Carcinoma. 



Cystic Encephaloid Carcinoma. - 

done what he has set out to do, viz., constructed a 
systematic and strictly accurate treatise on mammary 
tumors, and brought to his task all the light afforded 
by the most recent investigations into their pathol- 
ogy." — St. Louis Clinical Record. 

" This book is a real contribution to our profes* 
sional literature ; and it comes from a source which 
commands our respect. The plan is very systematic 
and complete, and the student or practitioner alike 
will find exactly the information he seeks upon any 
of the diseases which are incident to the mammary 
gland." — Obstetrical Gazette. 

" Altogether, the work is one of more than ordi 
nary interest to the surgeon, gynaecologist, and phy- 
sician." — Detroit Lancet. 

"The work is at once original, scientific, and 
practical. Its histology will receive the careful at- 
tention of the specialist ; the surgeon will find it a 
guide and help ; while the general practitioner, who 
would be informed, and desires to know what will 
be taught in our text-books and in our colleges, 
must study it. It is an effort' that will add new 
honor to an honorable name, and of which we, as 
/ mericans, may all be proud as an example of origi- 
nal work and investigation." — Buffalo Medical and 
Surgical Journal. 

" Dr. Gross has given to the profession, in his 
1 Treatise on Tumors of the Mammary Gland,' one 
of the most useful and original surgical works of the 
nineteenth century. It is but honest and just praise 
to say that in this treatise the author shows himself 
the intellectual peer of his great father, America's 
great surgeon." — Louisville Medical News. 

"A treatise based upon the systematic analysis 
of so large an amount of material can not fail to 
recommend itself to the intelligent surgeon, espe- 
cially as it, so far as we know, is the only recent 
work published which affords any trustworthy in- 
formation on this important subject. The author 
shows an intimate knowledge of the investigations 
of others, and refers to them frequently throughout 
the work, a fact which materially adds to its value." 
— Philadelphia Medical and Surgical Reporter. 

"He deserves the thanks of the profession for 
his bold and direct opinions, and doubtless in the 
future the general surgical practitioner will attack 
these tumors with more painstaking, and with more 
confidence in the results." — North Carolina Medi- 
cal Journal. 



i6 



D. APPLETON &* CO.'S MEDICAL WORKS. 



EMERGENCIES, AND HOW TO TREAT THEM. 

The Etiology, Pathology, and Treatment of Accidents, Diseases, and Cases 
of Poisoning, which demand Prompt Action. Designed for Students and 
Practitioners of Medicine. By Joseph W. Howe, M. D., Clinical Profess- 
or of Surgery in the Medical Department of the University of New York, 

etc., etc. 

Fourth edition, revised. I vol., 8vo, 265 pp. Cloth, $2.50. 



1 ' To the general practitioner in towns, villages, 
and in the country, where the aid and moral sup- 
port of a consultation can not be availed of, this 
volume will be recognized as a valuable help. We 
commend it to the profession." — Cincinnati Lancet 
a7id Observer. 

' ' The author wastes no words, but devotes him- 
self to the description of each disease as if the pa- 
tient were under his hands. Because it is a good 



book we recommend it most heartily to the profes- 
sion." — Boston Medical and Surgical Journal. 

" This work bears evidence of a thorough prac- 
tical acquaintance with the different branches of the 
profession. The author seems to possess a peculiar 
aptitude for imparting instruction as well as for 
simplifying tedious details. A careful perusal will 
amply repay the student and practitioner." — New 
York Medical Jour?ial. 



A TREATISE ON THE DISEASES OF THE NERV- 
OUS SYSTEM. By William A. Hammond, M. D., Surgeon-General 
U. S. Army (retired list) ; Professor of Diseases of the Mind and Nervous 
System, in the New York Post-Graduate Medical School; President of the 
American Neurological Association, etc. 

Seventh edition, rewritten, enlarged and improved. In one large 8vo vol. of 929 pp., with Com- 
plete Index and 150 Illustrations. Cloth, $5 ; sheep or half russia, $6. 

Specimen of Illustration. This, the seventh edition of 

Dr. Hammond's well-known 
work, has been thoroughly re- 
vised, and enlarged by the ad- 
dition of new chapters, and of 
a section on Diseases of the 
Sympathetic System. 

The work has received the 
honor of a French translation 
by Dr. Labadie-Lagrave, of 
Paris, and an Italian transla- 
tion by Professor Diodato Bor- 
relli, of the Royal University, 
is now going through the press 
at Naples. 

"Dr. Hammond's work has 
now been before the profession 
for many years, and its charac- 
teristics are very generally known. 
The present edition has a good 
many valuable additions, but has 
lost nothing of its previous indi- 
viduality as a medical work. Dr. Hammond has the qualities of a successful author. His practical ex- 
perience is large, his convictions are positive, and he can set them forth clearly and attractively. It is not 
surprising that his book has been a very popular one. And the present edition is, as modestly stated on 
the title-page, ' improved.' " — Medical Record. 




" This is unquestionably the most complete trea- 
tise on the diseases to which it is devoted that has 
yet appeared in the English language ; and its value 
is much increased by the fact that Dr. Hammond 
has mainly based it on his own experience and prac- . 
tice, which, we need hardly remind our readers, 
have been very extensive." — Medical Times and 
Gazette. 

"The author is a concise writer, who never 
wastes any paper, and he has, as he says himself in 
his preface, views of his own on every disease con- 
sidered, and he is not afraid to express them ; in 
short, the work is largely the result of his own ob- 
servation and experience, though the labors of others 
are by no means ignored." — Medical and Surgical 
Reporter ; Philadelphia. 



" It everywhere evinces comprehensive apprecia- 
tion of the scope of the subjects considered, offering 
what is known and at the same time indicating the 
paths by which further observation will lead to more 
perfect knowledge. It is a reliable guide to the 
study and treatment of a most highly interesting 
class of diseases, and will unquestionably maintain 
if not extend in its present form the approbation 
and appreciation its merits have hitherto com- 
manded." — New York Medical Gazette. 

" The merits of this book, like those of its au- 
thor, have not been hid under a bushel. It shows 
great facility of expression, much thought, and wide 
reading, with an uncommon faith in the power of 
remedies over diseases commonly found intract- 
able." — Louisville Medical News. 



D. APPLETON S* CO.'S MEDICAL WORKS. 



17 



"... We have only to wish this book a con- 
tinuance of its well-deserved popularity, and to 
recommend it to our readers as a work which any 
one who has to do with nervous diseases can not 
well afford to be without." — Dublin Medical Jour- 
nal. 

" Our space, and indeed the very nature of the 
work, forbids a detailed notice of the book. Suffice 
it to say that we are convinced, from a by no means 
superficial examination of it, that there is no work 
on the subject better adapted to the wants of the 
general practitioner at least." — Michigan Medical 
News. 

"We regard Dr. Hammond's work as excellent 
authority on the subject of nervous diseases, and 
frequently refer to it in our study of these affec- 
tions." — Canada Lancet. 

" Dr. Hammond's book is the only complete one 
on nervous diseases accessible to the English-read- 
ing student, which is the work of a competent writ- 
er, one who has observed, studied, and treated 
these affections himself." — St. Louis Clinical Rec- 
ord. 

"A careful examination shows this to be essen- 
tially a new volume, and the rewriting and remod- 
eling having wrought such changes, that it will be 
consulted with an increased degree of confidence by 
general practitioners." — North Carolina Medical 
Journal. 



Specimen of Illustration 



;;' '} 



: 



'i^/^fO 



tdi^ [ w v ° 



CLINICAL LECTURES ON DISEASES OF THE 

NERVOUS SYSTEM. Delivered at the Bellevue Hospital Medical Col- 
lege. By William A. Hammond, M. D., Professor of Diseases of the Mind 
and Nervous System, etc. Edited, with Notes, by T. M. B. Cross, M. D., 
Assistant to the Chairs of Diseases of the Mind and Nervous System, etc. 
In one handsome volume of 300 pages. $3.50. 

These lectures have been reported in full, and, together with the histories of the cases, which 
were prepared by the editor after careful study and prolonged observation, constitute a clinical 
volume which, while it does not claim to be exhaustive, will nevertheless be found to contain 
many of the more important affections of the kind that are commonly met with in practice. 

As these lectures were intended especially for the benefit of students, the author has confined 
himself to a full consideration of the symptoms, causes, and treatment of each affection, without 
attempting to enter into the pathology or morbid anatomy. 



THE ANATOMY OF VERTEBRATED ANIMALS. 

By Thomas Henry Huxley, LL. D., F. R. S. 

I vol., i2mo. Illustrated. 431 pp. Cloth, $2.50. 

" The present work is intended to provide students of comparative anatomy with a condensed 
statement of the most important facts relating to the structure of vertebrated animals which have 
hitherto been ascertained. The Vertebrata are distinguished from all other animals by the circum- 
stance that a transverse and vertical section of the body exhibits two cavities completely separated 
from one another by a partition. The dorsal cavity contains the cerebro-spinal nervous system ; 
the ventral, the alimentary canal, the heart, and usually a double chain of ganglia, which passes 
under the name of the ' sympathetic. ' It is probable that this sympathetic nervous system repre- 
sents, wholly or partially, the principal nervous system of the Annulosa and Mollusca. And, in 
any case, the central parts of the cerebro-spinal nervous system, viz., the brain and the spinal 
cord, would appear to be unrepresented among invertebrated animals." — The Author. 



' ' This long-expected work will be cordially wel- 
comed by all students and teachers of Comparative 
Anatomy as a compendious, reliable, and, notwith- 
standing' its small dimensions, most comprehensive 
guide on the subject of which it treats. To praise 
or to criticise the work of so accomplished a master 
of his favorite science would be equally out of place. 



It is enough to say that it realizes, in a remarkable 
degree, the anticipations which have been formed 
of it ; and that it presents an extraordinary combi- 
nation of wide, general views, with the clear, accu- 
rate, and succinct statement of a prodigious number 
of individual facts." — Nature. 



i8 



D. APPLETON &* CO.'S MEDICAL WORKS. 



A TREATISE ON ORAL DEFORMITIES, as a Branch 

c£ Mechanical Surgery. By Norman W. Kingsley, M. D. S., D. D. S., 
President of the Board of Censors of the State of New York, late Dean of 
the New York College of Dentistry and Professor of Dental Art and Mech- 
anism, etc., etc. 



With over 350 Illustrations. 

Specimen of Illustration. 



One vol., 8vo. Cloth, $5 ; sheep, $6. 

" I have read with great pleasure and much 
profit your valuable ' Treatise on Oral Deformi- 
ties.' The work contains much original matter 
of great practical value, and is full of useful in- 
formation, which will be of great benefit to the 
profession."— Lewis A. Sayre, M. D., LL. D., 
Professor of Orthopedic Surgery and Clinical 
Surgery, Bellevue Hospital Medical College. 

' ' A casual glance at this work might impress 
the reader with the idea that its contents were of 
more practical value to the dentist than to the 
general practitioner or surgeon. But it is by no 
means a mere work on dentistry, although a prac- 
tical knowledge of the latter art seems to be es- 
sential to the carrying out of the author's views 
regarding the correction of the different varieties 
of oral deformities of which he treats. We would 
be doing injustice to the work did not we make 
particular reference to the masterly chapter on the 
treatment of fractures of the lower jaw. The 
whole subject is so thoroughly studied that noth- 
ing is left to be desired by any surgeon who wish- 
es to treat these fractures intelligently and success- 
fully. The work, as a whole, bears marks of 
originality in every section, and impresses the 
reader with the painstaking efforts of the author 
to get at the truth, and apply it in an ingenious 
and practical way to the wants of the general 
practitioner, the surgeon, and the dentist."— 
Medical Record. 

" The profession is to be congratulated on 
possessing so valuable an addition to its litera- 
ture, and the author to be unstintedly praised for his successful issue to an arduous undertaking. The work 
bears, in a word, every evidence of having been written leisurely and with care. . . ."—Dental Cosmos. 

" To the surgeon and general practitioner of medicine, as well as the dentist, its instruction will be 

found invaluable. It is clear in style, practical in its application, comprehensive in its illustrations, and so 

exhaustive that it is not likely to meet in these respects a rival."— William H. Dwinelle, A. M., M. D. 

" I consider it to be the most valuable work that has ever appeared in this country in any department 

of the science of dental surgery. t 

"There is no doubt of its great value to every man who wishes to study and practice this branch 
of surgery, and I hope it may be adopted as a text-book in every dental college, that the students may 
have the benefit of the great experience of the 




author. 

" It places many things between the covers of 
one book which heretofore I have been obliged to 
look for in many directions, and often without 
success."— Frank Abbot, M. D., Dean of the 
New York College of Dentistry. 

" The writer does not hesitate to express his 
belief that the chapters on the ' aesthetics of den- 
tistry ' will be found of more practical value to 
the prosthetic dentist than all the other essays 
on this subject existent in the English language. 
... A perusal of its pages seems to compel the 
mind to advance in directions variously indi- 
cated ; so variously, indeed, that there is hardly 
a page of the book which does not contain some 
important truth, some pregnant hint, or some 
valuable conclusion." — Dental Miscellany. 

"I congratulate you on having written a 
book containing so much valuable and original 
matter. It will prove of value not only to den- 
tists, but also to surgeons and physicians." — 
Frank Hastings Hamilton, M. D., LL. D., 
Professor of the Practice of Surgery with Opera- 
tions, and of Clinical Surgery in Bellevue Hos- 
pital Medical College. 



Specimen of Illustration. 
Illlillllll 




D. APPLETON &* CO.'S MEDICAL WORKS, 



19 



THE BREATH, AND THE DISEASES WHICH GIVE 

IT A FETID ODOR. With Directions for Treatment. By Joseph W. 
Howe, M. D., Clinical Professor of Surgery in the Medical Department of 
the University of New York, etc. 

Second edition, revised and corrected. 1 vol., i2mo, 108 pp. Cloth, $1. 

" This little volume well deserves the attention 
of physicians, to whom we commend it most high- 
ly." — Chicago Medical Journal. 

" To any one suffering from the affection, either 
in his own person or in that of his intimate ac- 
quaintances, we can commend this volume as con- 
taining all that is known concerning the subject, set 



forth in a pleasant style." — Philadelphia Medical 
Times. 

' ' The author gives a succinct account of the dis- 
eased conditions in which a fetid breath is an im- 
portant symptom, with his method of treatment. 
We consider the work a real addition to medical lit- 
erature." — Cincinnati Medical Journal. 



ON THE BILE, JAUNDICE, AND BILIOUS DIS- 
EASES. By J. Wickham Lego, M. D., F. R. C. S., Assistant Physician to 
St. Bartholomew's Hospital, and Lecturer on Pathological Anatomy in the 
Medical School. 

In one volume, 8vo, 719 pp. With Illustrations in Chromo-lithography. Cloth, $6; sheep, $7. 



"... And let us turn — which we gladly do — to 
the mine of wealth which the volume itself contains, 
for it is the outcome of a vast deal of labor ; so 
great indeed, that one unfamiliar with it would be 
surprised at the number of facts and references 
which the book contains." — Medical Times and Ga- 
zette, London. 

" The book is an exceedingly good one, and, in 
some points, we doubt if it could be made better. 
. . . And we venture to say, after an attentive 
perusal of the whole, that any one who takes it 
in hand will derive from it both information and 
pleasure ; it gives such ample evidence of honest 
hard work, of wide reading, and an impartial at- 
tempt to state the case of jaundice, as it is known 
by observation up to the present date. The book 
will not only live, but be in the enjoyment of a vig- 
orous existence long after some of the more popular 
productions of the present age are buried, past all 
hope of resurrection." — London Medical Record. 

"This portly tome contains the fullest account 
of the subjects of which it treats in the English lan- 
guage. The historical, scientific, and practical de- 
tails are all equally well worked out, and together 
constitute a repertorium of knowledge which no 
practitioner can well do without. The illustrative 
chromo-lithographs are beyond all praise." — Edin- 
burgh Medical Journal. 



" Dr. Legg's treatise is a really great book, ex- 
hibiting immense industry and research, and full of 
valuable information." — American Journal 0/ Med- 
ical Science. 

"It seems to us an exhaustive epitome of all 
that is known on the subject." — Philadelphia Medi- 
cal Times. 

"This volume is one which will command pro- 
fessional respect and attention. It is, perhaps, the 
most comprehensive and exhaustive treatise upon 
the subject treated ever published in the English 
language." — Maryland Medical Journal. 

" It is the work of one who has thoroughly stud- 
ied the subject, and who, when he finds the evi- 
dence conflicting on disputed points, has attempted 
to solve the problem by experiments and observa- 
tions of his own." — Practitioner, Lo?idon. 

"It is a valuable work of reference and a wel- 
come addition to medical literature. — Dublin Jour- 
nal of Medical Science. 

"... The reader is at once struck with the im- 
mense amount of research exhibited, the author 
having left unimproved no accessible source of in- 
formation connected with his subject. It is, indeed, 
a valuable book, and the best storehouse of knowl- 
edge in its department that we know of." — Pacific 
Medical and Surgical Journal. 



FIRST LINES OF THERAPEUTICS as Based on the 

Modes and the Processes of Healing, as occurring spontaneously in Dis- 
eases ; and on the Modes and the Processes of Dying as resulting naturally 
from Disease. In a Series of Lectures. By Alexander Harvey, M. A., 
M. D., Emeritus Professor of Materia Medica in the University of Aber- 
deen, etc., etc. 

1 vol., i2mo, 278 pp. Cloth, $1.50. 



" If only it can get a fair hearing before the pro- 
fession it will be the means of aiding in the devel- 
opment of a therapeutics more rational than we 
now dream of. To medical students and practi- 
tioners of all sorts it will open up lines of thought 
and investigation of the utmost moment." — Detroit 
\Lancet. 



"We may say that, as a contribution to the 
philosophy of medicine, this treatise, which may be 
profitably read during odd moments of leisure, has 
a happy method of statement and a refreshing free- 
dom from dogmatism."— New York Medical Rec- 
ord. 



20 



D. APPLETON &* CO.'S MEDICAL WORKS. 



THE SCIENCE AND ART OF MIDWIFERY. By 

William Thompson Lusk, M. A., M. D., Professor of Obstetrics and Dis- 
eases of Women and Children in the Bellevue Hospital Medical College ; 
Obstetric Surgeon to the Maternity and Emergency Hospitals ; and Gynae- 
cologist to the Bellevue Hospital. 

New edition. Revised and enlarged. Complete in one volume, Svo, with 246 Illustrations. 

Cloth, $5.00; sheep, $6.00. „ It contains one of th£ best ^ 

positions of the obstetric science and' 
practice of the day with which we 
are acquainted. Throughout the 
work the author shows an intimate 
acquaintance with the literature of 
obstetrics, and gives evidence of large 
practical experience, great discrimi- 
nation, and sound judgment. We 
heartily recommend the book as a 
full and clear exposition of obstetric 
science and safe guide to student and 
practitioner." — London Lancet. 

" Professor Lusk's book presents 
the art of midwifery with all that 
modern science or earlier learning 




it. 



-Medical 



has contributed to 
Record, JSiew York. 

"This book bears evidence on 
every page of being the result of 
patient and laborious research and 
great personal experience, united 
and harmonized by the true critical 
or scientific spirit, and we are con- 
vinced that the book will raise the 
general standard of obstetric knowl- 
edge both in his own country and 
in this. Whether for the student obliged to learn the theoretical part of midwifery, or for the busy prac- 
titioner seeking aid in face of practical difficulties, it is, in our opinion, the best modern work on mid- 
wifery in the English language." — Dublin Journal of Medical Science. 



D'Outrepont's Method, modified by Scan: 




Author's Modification of Tarnier's Forceps. 



" Dr. Lusk's style is clear, generally concise, and 
he has succeeded in putting in less than seven hun- 
dred pages the best exposition in the English lan- 
guage of obstetric science and art. The book will 
prove invaluable alike to the student and the prac- 
titioner." — American Practitioner. 

" Dr. Lusk's work is so comprehensive in design 
and so elaborate in execution that it must be recog- 
nized as having a status peculiarly its own among 
the text-books of midwifery in the English lan- 
guage." — New York Medical Journal. 

"The work is, perhaps, better adapted to the 
wants of the student as a text-book, and to the 
practitioner as a work of reference, than any other 
•one publication on the subject. It contains about 
all that is known of the ars obstetrica, and must 
add greatly to both the fame and fortune of the 
distinguished author." — Medical Herald, Louis- 
ville. 



"Dr. Lusk's book is eminently viable. It can 
not fail to live and obtain the honor of a second, a 
third, and nobody can foretell how many editions. 
It is the mature product of great industry and acute 
observation. It is by far the most learned and most 
complete exposition of the science and art of obstet- 
rics written in the English language. It is a book 
so rich in scientific and practical information, that 
nobody practicing obstetrics ought to depiive him- 
self of the advantage he is sure to gain from a fre- 
quent recourse to its pages." — American Journal of 
Obstetrics. 

"It is a pleasure to read such a book as that 
which Dr. Lusk has prepared ; everything pertain- 
ing to the important subject of obstetrics is dis- 
cussed in a masterly and captivating manner. We 
recommend the book as an excellent one, and feel 
confident that those who read it will be amply re- 
paid."— Obstetric Gazette, Cincinnati. 



D. APPLETON &* CO.'S MEDICAL WORKS. 



21 



"To consider the work in detail 
would merely involve us in a reitera- 
tion of the high opinion we have al- 
ready expressed of it. What Spiegel- 
berg has done for Germany, Lusk, 
imitating him but not copying him, 
has done for English readers, and we 
feel sure that in this country, as in 
America, the work will meet with a 
very extensive approval." — Edinburgh 
Medical Journal. 

" The whole range of modern ob- 
stetrics is gone over in a most system- 
atic manner, without indulging in the 
discussion of useless theories or con- 
troversies. The style is clear, concise, 
compact, and pleasing. The illustra- 
tions are abundant, excellently exe- 
cuted, remarkably accurate in outline 
and detail, and, to most of our Ameri- 
can readers, entirely fresh." — Cincin- 
nati Lancet a?td Clinic. 

"We thank Dr. Lusk for his most 
valuable work, which is, in our opin- 
ion, as we have said before, the best 
representative of the state of obstetric 
science and art at the present day that 
exists in the English language. Stu- 
dent and practitioner will alike find it suitable to their needs, and there are few specialists who will 
not gain instruction from it." — Medical Times and Gazette, London. 

" This is undoubtedly the best book on the sub- "A work which, like the one before us, com- 

ject in the language. It is written from a physio- bines the qualities of being a safe and reliable guide 




Appearance of Cervix in Multipara; Ninth Month. 



logical stand-point, combined with an extended 
clinical knowledge. It is evident that teachers of 
obstetrics will not only be glad to commend such a 
work to their pupils, but will find it a most valuable 
guide for themselves." — Chicago Medical Review. 



to the practitioner, at the same time that it presents 
to the reader a fair statement of the labors of recent 
investigators, can not but prove useful." — Medical 
and Surgical Reporter, Philadelphia. 



HEALTH PRIMERS. Edited by J. Langdon Down, M. D., 
F. R. C. P. ; Henry Power, M. B., F. R. C. S. ; J. Mortimer-Granville, 
M. D. ; John Tweedy, F. R. C. S. 

In square i6mo volumes. Cloth, 40 cents each. 

Though it is of the greatest importance that books upon health should be in the highest degree 
trustworthy, it is notorious that most of the cheap and popular kind are mere crude compilations 
of incompetent persons, and are often misleading and injurious. Impressed by these considera- 
tions, several eminent medical and scientific men of London have combined to prepare a series of 
Health Primers of a character that shall be entitled to the fullest confidence. They are to be 
brief, simple, and elementary in statement, filled with substantial and useful information suitable 
for the guidance of grown-up people. Each primer will be written by a gentleman specially com- 
petent to treat his subject, while the critical supervision of the books is in the hands of a commit- 
tee who will act as editors. 

As these little books are produced by English authors, they are naturally based very much 
upon English experience, but it matters little whence illustrations upon such subjects are drawn, 
because the essential conditions of avoiding disease and preserving health are to a great degree 
everywhere the same. 

Volumes now ready. 

I. Exercise and Training. 

II. Alcohol : its Use and Abuse. 

III. Premature Death : its Promotion and Prevention. 

IV. The House and its Surroundings. 

V. Personal Appearance in Health and Disease. 
VI. Baths and Bathing. 
VII. The Skin and its Troubles. 
VIII. The Heart and its Functions. 
IX. The Nervous System. 



22 D. APPLETON &° CO.'S MEDICAL WORKS. 

ANALYSIS OF THE URINE. With Special Reference to 

the Diseases of the Genito-Urinary Organs. By M. B. Hoffman, Professor 
in the University of Gratz, and R. Ultzmann, Docent in the University of 
Vienna. Translated from the German edition under the special super- 
vision of Dr. Ultzmann. By T. Barton Brune, A. M., M. D., Resident 
Physician Maryland University Hospital, and H. Holbrook Curtis, Ph. B. 
With Eight Lithographic Colored Plates from Ultzmann and Hoffman's 
Atlas, and from Photographs furnished by Dr. Ultzmann, which do not 
appear in the German edition or any other translation. 
I vol., 8vo, 200 pages. $2. 

"We have not space for further analysis of the sis of the urine and diseases of the kidney, it ad- 
work, but would simply state that it well deserves mirably well fulfills the purpose of its being, viz., 
the reputation it has already obtained abroad. It is to concisely yet clearly present to the student an ac- 
eminently practical, and adapted, as the authors count of the normal and abnormal constituents of 
claim, to the wants of the physician and student the urine, the methods of their detection, and of 
rather than of the medical chemist, although the their diagnostic significance in general and local 
latter can ill afford to dispense with it." — Philadel- disease." — Southern Practitioner, 
phia Medical Times. < < We indorse the statement that the book is fully 

"At the present time we are unacquainted with up to the times, and heartily recommend it to stu- 
any work at all equal to this in meeting the needs dents and practitioners of medicine as the most use- 
of the medical student. The elegant form in which f ul and concise book on the subject. The practi- 
the publishers have issued it adds still further to its tioner, when he reads this little book, will be as- 
desirable qualities." — Detroit Lancet. tonished at the simplicity of ordinary urinalyses, 

"Throughout, the book is characterized by sound and » instead of sending to experts, will save time 

doctrine, scientific accuracy, and careful compila- and tr ° ub ! e b ? ma kmg them for himself."— Louis 



tion ; while, as a translation from a foreign tongue, 



ville Medical News. 



its lucidity of style, terseness, and perspicuity are " An examination of the book satisfies us that it 

veritably surprising. It can not fail, in our opin- has been carefully prepared, and can be relied on 

ion, to attain the end set before its authors in its for correctness. The new chemical notation is used, 

preparation, and prove a most valuable aid alike to and also the metrical system of weights and meas- 

student and practitioner in the urological diagnosis ures. As an appendix to the text, eight colored 

and study of disease. Eight very good double plates illustrate the solid constituents of the urine, 
plates, portraying the microscopic deposits of the « n the whole, we regard the book as well 

urine, complete the book."— Canada Journal of adapted to its purpose, and a decided convenience 

Medical Science. t t he practitioner who aims at something beyond 

" We advise our readers to procure the Apple- guess-work in diagnosis and prognosis of urinary 

tons' edition by all means ; making no pretensions disorders." — New York Medical and Surgical 

to be an exhaustive treatise on the subject of analy- Journal. 

CLINICAL ELECTRO-THERAPEUTICS. (Medical and 

Surgical.) A Manual for Physicians for the Treatment more especially of 

Nervous Diseases. By Allan McLane Hamilton, M. D., Physician in 

charge of the New York State Hospital for Diseases of the Nervous System, 

etc., etc. 

With numerous Illustrations. I vol., 8vo. Cloth, $2. 

This work is the compilation of well-tried measures and reported cases, and is intended as a 
simple guide for the general practitioner. It is as free from confusing theories, technical terms, 
and unproved statements as possible. Electricity is indorsed as a very valuable remedy in certain 
diseases, and as an invaluable therapeutical means in nearly all forms of Nervous Disease j but 
not as a specific for every human ill, mental and physical. 

THE ANATOMY OF INVERTEBRATED ANIMALS. 

By Thomas Henry Huxley, LL. D., F. R. S. 

I vol., i2mo. Illustrated. 596 pp. Cloth, $2.50. 

" My object in writing the book has been to make it useful to those who wish to become ac- 
quainted with the broad outlines of what is at present known of the morphology of the Inverte- 
brata ; though I have not avoided the incidental mention of facts connected with their physiology 
and their distribution. On the other hand, I have abstained from discussing questions of etiol- 
ogy, not because I underestimate their importance, or am insensible to the interest of the great 
problem of evolution, but because, to my mind, the growing tendency to mix up etiological^ specu- 
lations with morphological generalizations will, if unchecked, throw biology into confusion." — 
From Preface. 



D. APPLETON &* CO.'S MEDICAL WORKS. 



23 



HAND-BOOK OF SKIN DISEASES. By Dr. Isidor 

Neumann, Lecturer on Skin Diseases in the Royal University of Vienna. 

Translated from the German, second edition, with Notes, by Lucius D. 

Bulkley, A. M., M. D., Surgeon to the New York Dispensary, Department 

of Venereal and Skin Diseases ; Assistant to the Skin Clinic of the College 

of Physicians and Surgeons, New York, etc., etc. 

I vol., 8vo, 467 pp., and 66 Woodcuts. Cloth, $4; sheep, $5. 

Professor Neumann ranks sec- 
ond only to Hebra, whose assist- 
ant he was for many years, and his 
work may be considered as a fair 

exponent of the German practice i\ ■ ,. , v *iV 

of Dermatology. The book is 
abundantly illustrated with plates 
of the histology and pathology of 
the skin. The translator has en- 
deavored, by means of notes from 
French, English, and American 
sources, to make the work valua- 
ble to the student as well as to the 
practitioner. 



h 




" It is a work which I shall hearti- 
ly recommend to my class of students 
at the University of Pennsylvania, 7l- 
and one which I feel sure will do 
much toward enlightening the pro- 
fession on this subject." — Louis A. 
Duhring. ff ' 

41 There certainly is no work ex- 
tant which deals so thoroughly with 
the Pathological Anatomy of the Skin 
as does this hand-book." — New York 
Medical Record. 

" I have already twice expressed 
my favorable opinion of the book in f, 
print, and am glad that it is given to 
the public at last." — James C. White, 
Boston. 

" More than two years ago we 
noticed Dr. Neumann's admirable 
work in its original shape, and we are 
therefore absolved from the necessity 
of saying more than to repeat our 
strong recommendation of it to Eng- 
lish readers." — Practitioner. 




|P'\p 



V/rHWifth 



^^^ 



Lichen scrofulosorum. 



THE PATHOLOGY OF MIND. Being the third edition 

of the Second Part of the " Physiology and Pathology of Mind," recast, 
enlarged, and rewritten. By Henry Maudsley, M. D., London. 
I vol., l2mo, 580 pp. $2. 

CONTENTS.— Chapter I. Sleeping and Dreaming; II. Hypnotism, Somnambulism, and 
Allied States ; III. The Causation and Prevention of Insanity : ( A) Etiological ; IV. The same 
continued; V. The Causation and Prevention of Insanity : (B; Pathological; VI. The Insanity of 
Early Life; VII. The Symptomatology of Insanity; VIII. The same continued; IX. Clinical 
Groups of Mental Disease; X. The Morbid Anatomy of Mental Derangement; XI. The Treat- 
ment of Mental Disorders. 

The new material includes chapters on "Dreaming," " Somnambulism and its Allied States," 
and large additions in the chapters on the " Causation and Prevention of Insanity." 

"Unquestionably one of the ablest and most "Dr. Maudsley has had the courage to under- 

important works on the subject of which it treats take, and the skill to execute, what is, at least in 
that has ever appeared, and does credit to his philo- English, an original enterprise." — London Satur- 
sophical acumen and accurate observation." — Medi- day Review. 
cal Record. 



24 



D. APPLETON &» CO.'S MEDICAL WORKS. 



MEDICAL RECOLLECTIONS OF THE ARMY OF 

THE POTOMAC. By Jonathan Letterman, M. D., late Surgeon 
U. S. A., and Medical Director of the Army of the Potomac. 
I vol., 8vo, 194 pp. Cloth, $1. 



" We venture to assert that but few who open 
this volume of medical annals, pregnant as they are 



with instruction, will care to do otherwise than 
finish them at a sitting." — Medical Record. 



RESPONSIBILITY IN MENTAL 

Henry Maudsley, M. D., London. 



I vol., i2mo, 313 pp 

1 ' This book is a compact presentation of those 
facts and principles which require to be taken into 
account in estimating human responsibility — not le- 
gal responsibility merely, but responsibility for con- 
duct in the family, the school, and all phases of 



Cloth, $1.50. 



DISEASES. By 



social relation, in which obligation enters as an 
element. The work is new in plan, and was writ- 
ten to supply a wide-felt want which has not hither- 
to been met." — The Popular Science Monthly. 



BODY AND MIND: An Inquiry into their Connection and 

Mutual Influence, especially in reference to Mental Disorders ; an enlarged 

and revised edition, to which are added Psychological Essays. By Henry 

Maudsley, M. D., London. 

I vol., i2mo, 275 pp. Cloth, $1.50. 

The general plan of this work may be described as being to bring man, both in his physical 
and mental relations, as much as possible within the scope of scientific inquiry. 



" Dr. Maudsley has had the courage to under- 
take, and the skill to execute, what is, at least in 
English, an original enterprise. This book is a 
manual of mental science in all its parts, embracing 
all that is known in the existing state of physiology. 
. . . Many and valuable books have been written 
by English physicians on insanity, idiocy, and all 
the forms of mental aberration. But derangement 
had always been treated as a distinct subject, and 
therefore empirically. That the phenomena of 
sound and unsound minds are not matters of dis- 
tinct investigation, but inseparable parts of one and 
the same inquiry, seems a truism as soon as stated. 
But, strange to say, they had always been pursued 
separately, and been in the hands of two distinct 
classes of investigators. The logicians and meta- 
physicians occasionally borrowed a stray fact from 



the abundant cases compiled by the medical author- 
ities ; but the physician, on the other hand, had no 
theoretical clew to his observations beyond a smat 
tering of dogmatic psychology learned at college, 
To effect a reconciliation between the Psychology 
and the Pathology of the mind, or rather to con- 
struct a basis for both in a common science, is the 
aim of Dr. Maudsley 's book." — London Saturday 
Review. 

"A representative work, which everyone must 
study who desires to know what is doing in the way 
of real progress, and not mere chatter, about men- 
tal physiology and pathology." — Lancet. 

"It distinctly marks a step in the progress of 
scientific psychology." — The Practitioner. 



HEALTH, AND HOW TO PROMOTE IT. By Richard 

McSherry, M. D., Professor of Practice of Medicine, University of Mary- 
land ; President of Baltimore Academy of Medicine, etc. 
1 vol., l2mo, 185 

"An admirable production which should find its 
way into every family in the country. It comprises 
a vast amount of the most valuable matter expressed 
in clear and terse language, and the subjects of 
which it treats are of the deepest interest to every 
human being."— Prof. S. D. Gross, of Jefferson 
Medical College, Philadelphia. 

" On the whole, this little book seems to us very 
well adapted to its purpose, and will, we hope, have 
a wide circulation, when it can not fail to do much 
good." — American Journal of Medical Sciences. 

"It is the work of an able physician, and is 
written in a style which all people can understand. 
It deals with practical topics, and its ideas are set 
forth so pointedly as to make an impression." — 
The Tndependent. 



pp. Cloth, $1.25. 

" This is a racy little book of 185 pages, full of 
good advice and important suggestions, and written 
in a free and easy style, which crops out in con- 
tinued humor and crispness by which the advice is 
seasoned, and which render the reading of the book 
a pleasant pastime to all, whether professionals or 
non-professionals." — Canadian Journal of Medical 
Sciejice. 

" It contains a great deal of useful information, 
stated in a very simple and attractive way." — Balti- 
more Gazette. 

1 ' This is one of the best popular essays on the 
subject we have ever seen. It is short, clear, posi- 
tive, sensible, bright and entertaining in its style, 
and is as full of practical suggestions as a nut is 
full of meat." — Literary World. 



D. APPLETON &* CO.'S MEDICAL WORKS. 



25 



THE PHYSIOLOGY OF THE MIND. Being the First 

Part of a third edition, revised, enlarged, and in a great part rewritten, of 

" The Physiology and Pathology of the Mind." / By Henry Maudsley, 

M. D., London. 

1 vol., i2mo, 547 pp. Cloth, $2. 

CONTENTS.— Chapter I. On the Method of the Study of the Mind; II. The Mind and the 
Nervous System; III. The Spinal Cord, or Tertiary Nervous Centers; or, Nervous Centers of 
Reflex Action; IV. Secondary Nervous Centers, or Sensory Ganglia; Sensorium Commune; V. 
Hemispherical Ganglia; Cortical Cells of the Cerebral Hemispheres; Ideational Nervous Cen- 
ters ; Primary Nervous Centers; Intellectorium Commune; VI. The Emotions ; VII. Volition; 
VIII. Motor Nervous Centers, or Motorium Commune and Actuation or Effection ; IX. Memory 
and Imagination. 

"The ' Physiology of the Mind,' by Dr. Mauds- 
ley, is a very engaging; volume to read, as it is afresh 
and vigorous statement of the doctrines of a grow- 
ing scientific school on a subject of transcendent 
moment, and, besides many new facts and impor- 
tant views brought out in the text, is enriched by an 



instructive display of notes and quotations from 
authoritative writers upon physiology and psychol- 
ogy ; and by illustrative cases, which add materi- 
ally to the interest of the book." — Popular Science 
Monthly. 



PHYSICAL EDUCATION ; or, THE HEALTH LAWS 

OF NATURE. By Felix L. Oswald, M. D. 

l2mo, cloth. $1. 



"Dr. Oswald is a medical man of thorough 
preparation and large professional experience, and 
an extensively traveled student of nature and of 
men. While in charge of a military hospital at 
Vera Cruz, his own health broke down from long 
exposure in a malarial region, and he then struck 
for the Mexican mountains, where he became direct- 
or of another medical establishment. He has also 
journeyed extensively in Europe, South America, 
and the United States, and always as an open-eyed, 
absorbed observer of nature and of men. The 
4 Physical Education ' is one of the most whole- 
some and valuable books that have emanated from 
the American press in many a day. Not only can 
everybody understand it, and, what is more, feel it, 
but everybody that gets it will be certain to read and 
re-read it. We have known of the positive and 
most salutary influence of the papers as they ap- 
peared in the ' Monthly,' and the extensive demand 
for their publication in a separate form shows how 
they have been appreciated. Let those who are able 
and wish to do good buy it wholesale and give it to 
those less able to obtain it." — The Popular Science 
Monthly. 

" Here we have an intelligent and sensible treat- 
ment of a subject of great importance, viz. , physi- 
cal education. We give the headings of some of 
the chapters, viz. : Diet ; In-door Life ; Out-door 
Life ; Gymnastics ; Clothing ; Sleep ; Recreation ; 
Remedial Education ; Hygienic Precautions ; Pop- 
ular Fallacies. These topics are discussed in a plain, 
common-sense style suited to the popular mind. 



Books of this character can not be too widely read." 
— Albany (N. Y.) Argus. 

"Dr. Oswald is as epigrammatic as Emerson, 
as spicy as Montaigne, and as caustic as Heine. 
And yet he is a pronounced vegetarian. His first 
chapter is devoted to a consideration of the diet 
suitable for human beings and infants. In the next 
two he contrasts life in and out of doors. He then 
gives his ideas on the subjects of gymnastics, cloth- 
ing, sleep, and recreation. He suggests a system of 
remedial education and hygienic precautions, and 
he closes with a diatribe against popular fallacies." 
— Philadelphia Press. 

" It is a good sign that books on physical train- 
ing multiply in this age of mental straining. Dr. 
Felix L. Oswald, author of the above book, may be 
somewhat sweeping in his statements and beliefs, 
but every writer who, like him, clamors for sim- 
plicity, naturalness, and frugality in diet, for fresh 
air and copious exercise, is a benefactor. Let the 
dyspeptic and those who are always troubling them- 
selves and their friends about their manifold ail- 
ments take Dr. Oswald's advice and look more to 
their aliments and their exercise." — New York 
Herald. 

" One of the best books that can be put in the 
hands of young men and women. It is very inter- 
esting, full of facts and wise suggestions. It points 
out needed reforms, and the way we can become a 
strong and healthy people. It deserves a wide cir- 
culation." — Boston Commonwealth. 



GALVANO -THERAPEUTICS. The Physiological and 

Therapeutical Action of the Galvanic Current upon the Acoustic, Optic, 
Sympathetic, and Pneumogastric Nerves. By William B. Neftel. 
Fourth edition. I vol., i2mo, 161 pp. Cloth, $1.50. 

This book has been republished at the request of several aural surgeons and other professional 
gentlemen, and is a valuable treatise on the subjects of which it treats. Its author, formerly visit- 
ing physician to the largest hospital of St. Petersburg, has had the very best facilities for investi- 
gation. 

"This little work shows, as far as it goes, full " Those who use electricity should get this work, 

knowledge of what has been done on the subjects and those who do not should peruse it to learn that 
treated of, and the author's practical acquaintance there is one more therapeutical agent that they could 
with them." — New York Medical Journal. and should possess." — The Medical Investigator. 



26 



D. APPLETON &* CO.'S MEDICAL WORKS. 



OVARIAN TUMORS ; their Pathology, Diagnosis, and Treat- 
ment, with Reference especially to Ovariotomy. By E. R. Peaslee, M. D., 
Professor of Diseases of Women in Dartmouth College ; formerly Professor 
of Obstetrics and Diseases of Women in the New York Medical College, etc. 

I vol., 8vo, 551 pp. Illustrated with many Woodcuts, and a Steel Engraving of Dr. E. McDow- 
ell, the "Father of Ovariotomy." Cloth, $5; sheep, $6. 

This valuable work, embracing the results of many years of successful experience in the de- 
partment of which it treats, will prove most acceptable to the entire profession ; while the high 
standing of the author and his knowledge of the subject combine to make the book the best in the 
language. Fully illustrated, and abounding with information, the result of a prolonged study of 
the subject, the work should be in the hands of every physician in the country. 

" In closing our review of this work, we can not 
avoid again expressing our appreciation of the thor- 
ough study, the careful and honest statements, and 
candid spirit, which characterize it. For the use of 
the student we should give the preference to Dr. 
Peaslee 's work, not only from its completeness, but 
from its more methodical arrangement ." — Ameri- 
can Journal of Medical Sciences. 



"We deem its careful perusal indispensable to 
all who would treat ovarian tumors with a good con- 
science." — American Journal of Obstetrics. 

" It shows prodigal industry, and embodies with- 
in its five hundred and odd pages pretty much all 
that seems worth knowing on the subject of ovarian 
diseases." — Philadelphia Medical Times. 



A TREATISE ON DISEASES OF THE BONES. By 

Thomas M. Markoe, M. D., Professor of Surgery in the College of Physi- 
cians and Surgeons, New York, etc. With numerous Illustrations. 
1 vol., 8vo, 416 pp. Cloth, $4.50. 

Specimen of Illustration. This valuable work is a trea- 

tise on Diseases of the Bones, 
embracing their structural 
changes as affected by disease, 
their clinical history and treat- 
ment, including also an account 
of the various tumors which 
grow in or upon them. None 
of the injuries of bone are in- 
cluded in its scope, and no joint 
diseases, excepting where the 
condition of the bone is a prime 
factor in the problem of disease. 
As the work of an eminent sur- 
geon of large and varied experi- 
ence, it may be regarded as the best on the subject, and a valuable contribution to medical 
literature. 

DR. PEREIRA'S ELEMENTS OF MATERIA MEDICA 

AND THERAPEUTICS. Abridged and adapted for the Use of Medical 
and Pharmaceutical Practitioners and Students, and comprising all the 
Medicines of the British Pharmacopoeia, with such others as are frequently 
ordered in Prescriptions, or required by the Physician. Edited by Robert 
Bentley and Theophilus Redwood. 
New edition. Brought down to 1872. 1 vol., royal 8vo, 1,093 pp. Cloth, $7; sheep, $8. 




NOTES ON NURSING: What it is, and what it is not. By 
Florence Nightingale. 

1 vol., i2mo, 140 pp. Cloth, 75 cents. 

These notes are meant to give hints for thought to those who have personal charge of the 
health of others. 

E very-day sanitary knowledge, or the knowledge of nursing, or, in other words, of how to put 
the constitution in such a state as that it will have no disease or that it can recover from disease, 
is recognized as the knowledge which every one ought to have— distinct from medical knowledge, 
which only a profession can have. 






D. APPLETON &* CO.'S MEDICAL WORKS. 



27 



A TEXT-BOOK OF PRACTICAL MEDICINE. With 

Particular Reference to Physiology and Pathological Anatomy. By the 
late Dr. Felix von Niemeyer, Professor of Pathology and Therapeutics ; 
Director of the Medical Clinic of the University of Tubingen. Translated 
from the eighth German edition, by special permission of the author, by 
George H. Humphreys, M. D., one of the Physicians to Trinity Infirmary, 
Fellow of the New York Academy of Medicine, etc., and Charles E. 
Hackley, M. D., one of the Physicians to the New York Hospital and 
Trinity Infirmary, etc. 

Revised edition of 1880. 2 vols., 8vo, 1,628 pages. Cloth, $9; sheep, $11. 

The author undertakes, first, to give a picture of disease which shall be as life-like and faithful 
to nature as possible, instead of being a mere theoretical scheme ; secondly, so to utilize the more 
recent advances of pathological anatomy, physiology, and physiological chemistry, as to furnish a 
clearer insight into the various processes of disease. 

The work has met with the most flattering reception and deserved success ; has been adopted 
as a text-book in many of the medical colleges both in this country and in Europe ; and has re- 
ceived the very highest encomiums from the medical and secular press. 



" This new American edition of Niemeyer fully 
sustains the reputation of previous ones, and may 
be considered, as to style and matter, superior to 
any translation that could have been made from the 
latest German edition. It will be recollected that 
since the death of Professor Niemeyer, in 1871, his 
work has been edited by Dr. Eugene Seitz. Although 
the latter gentleman has made many additions and 
changes, he has destroyed somewhat the individual- 
ity of the original. The American editors have 
wisely resolved to preserve the style of the author, 
and adhere, as closely as possible, to his individual 
views and his particular style. Extra articles have 
been inserted on chronic alcoholism, morphia-poi- 
soning, paralysis agitans, scleroderma, elephantiasis, 
progressive pernicious anaemia, and a chapter on 
yellow fever. The work is well printed as usual." 
— Medical Record. 

"The first inquiry in this country regarding a 
German book generally is, ' Is it a work of practi- 
cal value ? ' Without stopping to consider the just- 
ness of the American idea of the ' practical,' we can 



unhesitatingly answer, ' It is ! ' " — New York Medi- 
cal Journal. 

" It is comprehensive and concise, and is char* 
actenzed by clearness and originality." — Dublin 
Quarterly Journal of Medicine. 

44 Its author is learned in medical literature ; he 
has arranged his materials with care and judgment, 
and has thought over them." — The Lancet. 

44 While, of course, we can not undertake a re- 
view of this immense work of about 1,600 pages in 
a journal of the size of ours, we may say that we 
have examined the volumes very carefully, as to 
whether to recommend them to practitioners or not ; 
and we are glad to say, after a careful review, ' Buy 
the book.' The chapters are succinctly written. 
Terse terms and, in the main, brief sentences are 
used. Personal experience is recorded, with a' : prop- 
er statement of facts and observations by other au- 
thors who are to be trusted. A very excellent index 
is added to the second volume, which helps very 
much for ready reference." — Virginia Medical 
Monthly. 



ESSAYS ON THE FLOATING MATTER OF THE 

AIR, in Relation to Putrefaction and Infection. By Professor John Tyn- 
dall, F. R. S. 

l2mo. Cloth, $1.50. 

CONTENTS.— I. On Dust and Disease; II. Optical Deportment of the Atmosphere in Re- 
lation to Putrefaction and Infection; III. Further Researches on the Deportment and Vitality of 
Putrefactive Organisms; IV. Fermentation, and its Bearings on Surgery and Medicine; V. Spon- 
taneous Generation ; Appendix. 

44 In the book before us we have the minute de- 
tails of hundreds of observations on infusions ex- 
posed to optically pure air ; infusions of mutton, 
beef, haddock, hay, turnip, liver, hare, rabbit, 
grouse, pheasant, salmon, cod, etc. ; infusions 
heated by boiling water and by boiling oil, some- 
times for a few moments and sometimes for several 
hours, and, however varied the mode of procedure, 
the result was invariably the same, with not even a 
shade of uncertainty. The fallacy of spontaneous 
generation and the probability of the germ theory 
of disease seem to us the inference, and the only 
inference, that can be drawn from the results of 
nearly ten thousand experiments performed by Pro- 
fessor Tyndall within the last two years." — Pitts- 
burg Telegraph. 



44 Professor Tyndall's book is a calm, patient, 
clear, and thorough treatment of all the questions 
and conditions of nature and society involved in 
this theme. The work is lucid and convincing, yet 
not prolix or pedantic, but popular and really en- 
joyable. It is worthy of patient and renewed 
study. " — Philadelphia Times. 

44 The matter contained in this work is not only 
presented in a very interesting way, but is of great 
value." — Boston Journal of Commerce. 

44 The germ theory of disease is most intelli- 
gently presented, and indeed the whole work is 
instinct with a high intellect." — Boston Common- 
wealth. * 



2% 



D. APPLETON 6- CO:S MEDICAL WORKS. 



THE APPLIED ANATOMY OF THE NERVOUS 

SYSTEM, being a Study of this Portion of the Human Body from a Stand- 
point of its General Interest and Practical Utility, designed for Use as a 
Text-book and as a Work of Reference. By Ambrose L. Ranney, A. M., 
M. D., Adjunct Professor of Anatomy and late Lecturer on the Diseases of 
the Genito-Urinary Organs and on Minor Surgery in the Medical Depart- 
ment of the University of the City of New York, etc., etc. 
I vol., 8vo. Profusely illustrated. Cloth, $4; sheep, $5. 




Distribution of the Hypo-glossal Nerve. 



"This is a useful book, and one of novel de- 
sign. It is especially valuable as bringing together 
facts and inferences which aid greatly in forming 
correct diagnoses in nervous diseases." — Boston 
Medical and Surgical Journal. 

" This is an excellent work, timely, practical, 
and well executed. It is safe to say that, besides 
Hammond's work, no book relating to the nervous 
system has hitherto been published in this country 
equal to the present volume, and nothing superior 
to it is accessible to the American practitioner." — 
Medical Herald. 

" There are many books, to be sure, which con- 
tain here and there hints in this field of great value 
to the physician, but it is Dr. Ranney's merit to 
have collected these scattered items of interest, and 
to have woven them into an harmonious whole, 
thereby producing a work of wide scope and of cor- 
respondingly wide usefulness to the practicing physi- 
cian. 

" The book, it will be perceived, is of an emi- 
nently practical character, and, as such, is addressed 
to those who can not afford the time for the perusal 
of the larger text-books, and who must read as they 
run."— New York Medical Journal. 



" Professors of anatomy in schools and colleges 
can not afford to be without it. We recommend 
the book to practitioners and students as well." — 
Virginia Medical Monthly. 

" It is an admitted fact that the subject treated 
of in this work is one sufficiently obscure to the pro- 
fession generally to make any work tending to elu- 
cidation most welcome. 

" We earnestly recommend this work as one un- 
usually worthy of study." — Buffalo Medical and 
Surgical Journal. 

" Dr. Ranney has firmly grasped the essential 
features of the results of the latest study of the 
nervous system. His work will do much toward 
popularizing this study in the profession. 

'' We are sure that all our readers will be quite 
as much pleased as ourselves by its careful study." 
— Detroit Lancet. 

"A useful and attractive book, suited to the 
time." — Louisville Medical News. 

' ' Our impressions of this work are highly fa- 
vorable as regards its practical value to students, as 
well as to educated medical men." — Pacific Medical 
and Surgical Journal. 






D. APPLETON &° CO.'S MEDICAL WORKS. 



2 9 



"The work shows great care in 
its preparation. We predict for it a 
large sale among the more progres- 
sive practitioners." — Michigan Medi- 
cal News. 

" We are acquainted with no re- 
cent work which deals with the sub- 
ject so thoroughly as this ; hence, it 
should commend itself to a large class 
of persons, not merely specialists, but 
those who aspire to keep posted in 
all important advances in the science 
and art of medicine." — Maryland 
Medical Journal. 

"This work was originally ad- 
dressed to medical under-graduates, 
but it will be equally interesting and 
valuable to medical practitioners who 
still acknowledge themselves to be 
students. It is to be hoped that their 
number is not small." — New Orleans 
Medical and Surgical Journal. 

"We think the author has cor- 
rectly estimated the necessity for such 
a volume, and we congratulate him 
upon the manner in which he has 
executed his task. 

"Asa companion volume to the 
recent works on the diseases of the 
nervous system, it is issued in good 
time." — North Carolina Medical 
Journal. 

" A close and careful study of this 
work, we feel convinced, will impart 
to the student a large amount of practical knowledge which could not 
be gained elsewhere, except by wading through the enormous quan- 
tity of neurological literature which has appeared during past years, 
a task which few would have either time or inclination to accomplish. 
Here it will all be found condensed, simplified, and systematically 
arranged. The nature of the work is so fully explained in its title 
that little or nothing on that point need be said here. We will, how- 
ever, say that the whole subject is treated in a lucid manner, and that, 
so far as we are able to judge, nothing seems left out which could in 
any way improve or add to the value of the book." — Medical and 
Surgical Reporter {Philadelphia). 

"Dr. Ranney has done a most useful and praiseworthy task in 
that he will have saved many of the profession from the choice of 
going through the research we have indicated, or remaining in igno- 
rance of many things most essential to a sound medical knowledge." — Medical Record. 

"We are sure that this book will be well received, and will prove itself a very useful companion both 
for regular students of anatomy and physiology, and also for practitioners who wish to work up the diag- 
nosis of cases of disorder of the nervous system." — Canada Medical and Surgical Journal. 

" Dr. Ranney has done his work well, and given accurate information in a simple, readable style." — 
Philadelphia Medical Times. 




Th= Deep Hranch of the External 
Plantar Nerve. 




The Small Sciatic Nerve, with its 
Branches of Distribution and 
Termination. 



A MINISTRY OF HEALTH AND OTHER AD- 
DRESSES. By Dr. B. W. Richardson, M. D., M. A., F. R. S., etc., etc. 

I vol., i2mo, 354 pp. Cloth, $1.50. 



" The author is so widely and favorably known 
that any book which bears his name will receive re- 
spectful attention. He is one of those highly edu- 
cated yet practical, public-spirited gentlemen who 
adorn the profession of medicine and do far more 
than their share toward elevating its position before 
the public. This book, owing to the character of 
the matter considered and the author's attractive 
style, affords means for relaxation and instruction 
to every thoughtful person." — Medical Gazette. 

" This book is made up of a number of addresses 
on sanitary subjects, which Dr. Richardson deliv- 
ered at various times in Great Britain, and which 
are intended to invite attention to the pressing re- 
forms that are making progress in medical science. 
The work, which has the great merit of being writ- 



ten in the simplest and clearest language, gives 
special attention to the origin and causes of diseases, 
and a demonstration of the physical laws by which 
they may be prevented. . . . 

" The author does not, like some members of his 
profession, enter into a learned description of cures, 
but traces the causes of diseases with philosophical 
precision. The book contains what every one should 
know, and members of the medical profession will 
not find a study of it in vain." — Philadelphia En- 
quirer. 

" The wide study of these lectures by both the 
profession and the laity would greatly advance the 
interests of both by stimulating thought and action 
respecting the most vital subjects that can engage 
the human mind." — Detroit Lancet. 



3Q 



D. APPLETON &* COJS MEDICAL WORKS. 



DISEASES OF MODERN LIFE. By Dr. B. W. Richard- 
son, M. D., M. A., F. R. S., etc., etc. 

I vol., I2ijio, 520 pp. Cloth, $2. 

" In this valuable and deeply interesting- work of atmospheric temperature, of atmospheric press- 

Dr. Richardson treats the nervous system as the ure, of moisture, winds, and atmospheric chemical 

very principle of life, and he shows how men do it changes, which are of great general interest." — Na- 

violence, yet expect immunity where the natural sen- ture. 

tence is death."— Charleston Courier. « Particular attention is given to diseases from 

" The work is of great value as a practical guide worry and mental strain, from the passions, from 

to enable the reader to detect and avoid various alcohol, tobacco, narcotics, food, impure air, late 

sources of disease, and it contains, in addition, sev- hours, and broken sleep, idleness, intermarriage, 

eral introductory chapters on natural life and natu- etc., thus touching upon causes which do not enter 

ral death, the phenomena of disease, disease ante- into the consideration of sickness." — Boston Com- 

cedent to birth, and on the effects of the seasons, monwealth. 

THE WATERING-PLACES AND MINERAL SPRINGS 

OF GERMANY, AUSTRIA, AND SWITZERLAND. With Notes on 

Climatic Resorts and Consumption, Sanitariums, Peat, Mud, and Sand 

Baths, Whey and Grape Cures, etc. By Edward Gutmann, M. D 

With Illustrations, Comparative Tables, and a Colored Map, explaining the Situation and Chemi- 
cal Composition of the Spas. I vol., l2mo. Cloth, $2.50. 

" Dr. Gutmann has compiled an excellent medi- tions, with the therapeutical applications of the 

cal guide, which gives full information on the man- mineral waters, are very thoroughly presented in 

ners and customs of living at all the principal separate parts of the volume." — New York Times. 
watering-places in Europe. The chemical composi- 

A PRACTICAL MANUAL ON THE TREATMENT 

OF CLUB-FOOT. By Lewis A. Sayre, M. D., Professor of Orthopedic 
Surgery and Clinical Surgery in Bellevue Hospital Medical College ; Con- 
sulting Surgeon to Bellevue Hospital, Charity Hospital, etc., etc. 
Fourth edition, enlarged and corrected. I vol., i2mo. Illustrated. Cloth, $1.25. 

"Amore extensive experience in the treatment of club-foot has proved that the doctrines taught 
in my first edition were correct, viz., that in all cases of congenital club-foot the treatment should 
commence at birth, as at that time there is generally no difficulty that can not be overcome by the 
ordinary family physician ; and that, by following the simple rules laid down in this volume, the 
great majority of cases can be relieved, and many cured, without any operation or surgical inter- 
ference. If this early treatment has been neglected, and the deformity has been permitted to in- 
crease by use of the foot in its abnormal position, surgical aid may be requisite to overcome the 
difficulty ; and I have here endeavored to clearly lay down the rules that should govern the treat- 
ment of this class of cases." — Preface. 

"The book will very well satisfy the wants of use, as stated, it is intended.'' — New York Medical 
the majority of general practitioners, for whose Journal. 

COMPENDIUM OF CHILDREN'S DISEASES. A 

Hand-Book for Practitioners and Students. By Dr. Johann Steiner, 
Professor of the Diseases of Children in the University of Prague. Trans- 
lated from the second German edition by Lawson Tait, F. R. C. S., Sur- 
geon to the Birmingham Hospital for Women. 

1 vol., 8vo. Cloth, $3.50; sheep, $4.50. 

"Dr. Steiner's book has met with such marked success in Germany that a second edition has 
already appeared, a circumstance which has delayed the appearance of its English form, in order 
that I might be able to give his additions and corrections. 

" I have added as an Appendix the ' Rules for Management of Infants,' which have been issued 
by the staff of the Birmingham Sick Children's Hospital, because I think that they have set an ex- 
ample, by freely distributing these rules among the poor, for which they can not be sufficiently 
commended, and which it would be wise for other sick children's hospitals to follow. 

" I have also added a few notes, chiefly, of course, relating to the surgical ailments of chil- 
dren." — Extract from Translator 's Preface. 






D. APPLETON &* CO.'S MEDICAL WORKS. 



31 



HEALTH : A Hand-Book for Households and Schools. By 

Edward Smith, M. D., F. R. S., Fellow of the Royal College of Physicians 

and Surgeons of England, etc. 

1 vol., i2mo. Illustrated. 198 pp. Cloth, $1. 

It is intended to inform the mind on the subjects involved in the word Health, to show how 
health may be retained and ill-health avoided, and to add to the pleasure and usefulness of life. 



" The author of this manual has rendered a real 
service to families and teachers. It is not a mere 
treatise on health, such as would be written by a 
medical professor for medical students. Nor is it 
a treatise on the treatment of disease, but a plain, 
common-sense essay on the prevention of most of 
the ills that flesh is heir to. There is no doubt that 
much of the sickness with which humanity is af- 
flicted is the result of ignorance, and proceeds from 



the use of improper food, from defective drainage, 
overcrowded rooms, ill-ventilated workshops, im- 
pure water, and other like preventable causes. 
Legislation and municipal regulations may do 
something in the line of prevention, but the people 
themselves can do a great deal more — particularly 
if properly enlightened ; and this is the purpose of 
the book." — Albany Journal. 



LECTURES ON ORTHOPEDIC SURGERY AND DIS- 
EASES OF THE JOINTS. By Lewis A. Sayre, M. D., Professor of 
Orthopedic Surgery and Clinical Surgery in Bellevue Hospital Medical Col- 
lege ; Consulting Surgeon to Bellevue Hospital, Charity Hospital, etc., etc. 

Second edition, revised and greatly enlarged, with 324 Illustrations. I vol., 8vo, 569 pp. Cloth, 

$5; sheep, $6. 

This edition has been thoroughly revised and rearranged, and the subjects classified in the ana- 
tomical and pathological order of their development. Many of the chapters have been entirely 
rewritten, and several new ones added, and the whole work brought up to the present time, with 
all the new improvements that have been developed in this department of surgery. Many new 
engravings have been added, each illustrating some special point in practice. 

Specimen of Illustration. 




"The name of the author is a sufficient guar- 
antee of its excellence, as no man in America or 
elsewhere has devoted such unremitting attention 
for the past thirty years to this department of Sur- 
gery, or given to the profession so many new truths 
and laws as applying to the pathology and treat- 
ment of deformities." — Western Lajtcet. 

" The name of Lewis A. Sayre is so intimately 
connected and identified with orthopaedics in all its 
branches, that a book relating his experience can 
not but form an epoch in medical science, and prove 
a blessing to the profession and humanity. Dr. 
Sayre' s views on many points differ from those 
entertained by other surgeons, but the great suc- 
cesses he has obtained fully warrant him in main- 
taining the ' courage of his opinions.' " — American 
Journal of Obstetrics. 



"Dr. Sayre has stamped his individuality on 
every part of his book. Possessed of a taste for 
mechanics, he has admirably utilized it in so modi- 
fying the inventions of others as to make them of 
far greater practical value. The care, patience, and 
perseverance which he exhibits in fulfilling all the 
conditions necessary for success in the treatment of 
this troublesome class of cases are worthy of all 
praise and imitation." — Detroit Review of Medi- 
cine. 

"Its teaching is sound, and the originality 
throughout very pleasing ; in a word, no man 
should attempt the treatment of deformities of joint 
affections without being familiar with the views 
contained in these lectures." — Canada Medical and 
Surgical Journal. 



32 



D. APPLETON &• CO.'S MEDICAL WORKS. 



Index. 

Specimen of Illustration. 



LECTURES UPON DISEASES OF THE RECTUM 

AND THE SURGERY OF THE LOWER BOWEL. Delivered at 
the Bellevue Hospital Medical College by W. H. Van Buren, M. D., late 
Professor of the Principles and Practice of Surgery in the Bellevue Hospi- 
tal Medical College, etc., etc. 
Second edition, revised and enlarged, i volume, 8vo, 412 pp., with 27 Illustrations and complete 

Cloth, $3; sheep, $4. 

" The reviewer too often finds it a difficult 
task to discover points to praise, in order that 
his criticisms may not seem one-sided and un- 
just. These lectures, however, place him upon 
the other horn of the dilemma, viz., to find 
somewhat to criticise severely enough to clear 
himself of the charge of indiscriminating lau- 
dation. Of course, the author upholds some 
views which conflict with other authorities, but 
he substantiates them by the most powerful of 
arguments, viz., a large experience, the results 
of which are enunciated by one who elsewhere 
shows that he can appreciate, and accord the 
due value to, the work and experience of 
others." — Archives of Medicine. 

" The present is a new volume rather than 
a new edition. Both its size and material 
are vastly beyond its predecessor. The same 
scholarly method, the same calm, convincing 
statement, the same wise, carefully matured 
counsel, pervade every paragraph. The dis- 
comfort and dangers of the diseases of the 
rectum call for greater consideration than 
they usually receive at the hands of the pro- 
fession." — Detroit Lancet. 

' ' These lectures are twelve in number, and 
may be taken as an excellent epitome of our 
present knowledge of the diseases of the parts 
in question. The work is full of practical 
matter, but it owes not a little of its value to 
the original thought, labor, and suggestions 
as to the treatment of disease, which always 
characterize the productions of the pen of Dr. 
Van Buren." — Philadelphia Medical Times. 

' ' The most attractive feature of the work 
is the plain, common-sense manner in which 
each subject is treated. The author has laid down instructions for the treatment, medicinal and opera- 
tive, of rectal diseases in so clear and lucid style as that any practitioner is enabled to follow it. The 
large and successful experience of the distinguished author in this class of diseases is sufficient of itself to 
warrant the high character of the book." — Nashville Journal 0/ Medicine and Surgery. 

We have thus briefly tried to give the known to the profession as one of our most accom- 




:^f : y ' f 



reader an idea of the scope of this work : and the 
work is a good one— as good as either Allingham's 
or Curling's, with which it will inevitably be com- 
pared. Indeed, we should have been greatly sur- 
prised if any work from the pen of Dr. Van Buren 
had not been a good one ; and we have to thank 
him that for the first time we have an American 
text-book on this subject which equals those that 
have so long been the standards." — New York Med- 
ical Journal. 

' ' Mere praise of a book like this would be super- 
fluous—almost impertinent. The author is well 



plished surgeons and ablest scientific men. Much 
is expected of him in a book like the one before us, 
and those who read it will not be disappointed. It 
will, indeed, be widely read, and, in a short time, 
take its place as the standard American authority." 
— St. Louis Courier of Medicine. 

" Taken as a whole, the book is one of the most 
complete and reliable ones extant. It is certainly 
the best of any similar work from an American au- 
thor. It is handsomely bound and illustrated, and 
should be in the hands of every practitioner and 
student of medicine." — Louisville Medical Herald. 



REPORTS. Bellevue and Charity Hospital Reports for 1870, 
containing valuable contributions from Isaac E. Taylor, M. D., Austin 
Flint, M. D., Lewis A. Sayre, M. D., William A. Hammond, M. D., T. 
Gaillard Thomas, M. D., Frank H. Hamilton, M. D., and others. 

1 vol., 8vo, 415 pp. Cloth, $4. 
"These institutions are the most important, as connected with them are acknowledged to be among 
regards accommodations for patients and variety of the first in their profession, and the volume is an 
•ases treated, of any on this continent, and are sur- important addition to the professional literature of 
passed by but few in the -world. The gentlemen this country." — Psychological Journal. 



• D. APPLE TON &> CO.'S MEDICAL WORKS. 33 

THE POSTHUMOUS WORKS OF SIR JAMES YOUNG 

SIMPSON, Bart., M. D. In Three Volumes. 

Volume I. — Selected Obstetrical and Gynaecological Works of Sir 

James Y. Simpson. Edited by J. Watt Black, M. D. 

1 vol., 8vo, 852 pp. Cloth, $3; sheep, $4. 

This first volume contains many of the papers reprinted from his Obstetric Memoirs and Con- 
tributions, and also his Lecture Notes, now published for the first time, containing the substance 
of the practical part of his course of midwifery. It is a volume of great interest to the profession, 
and a fitting memorial of its renowned and talented author. 

Volume II. — Anesthesia, Hospitalism, etc. Edited by Sir Walter Simp- 
son, Bart. 

"We say of this, as of the first volume, that it maybe picked out and studied with pleasure and 
should find a place on the table of every practi- profit."— The Lancet {Loudon). 
tioner ; for, although it is patchwork, each piece 

I vol., 8vo, 560 pp. Cloth, $3 ; sheep, $4. 

Volume III. — Diseases of Women. Edited by Alexander Simpson, M. D. 
1 vol., 8vo, 789 pp. Cloth, $3; sheep, $4. 
One of the best works on the subject extant. Of inestimable value to every physician. 

ON FOODS. By Edward Smith, M. D., LL. B., F. R. S.> 

Fellow of the Royal College of Physicians of London, etc., etc. 

1 vol., i2mo, 485 pp. Cloth, $1.75. 

" Since the issue of the author's work on ' Prac- "The book contains a series of diagrams, dis- 

tical Dietary,' he has felt the want of another, which playing the effects of sleep and meals on pulsation 

would embrace all the generally known and some and respiration, and of various kinds of food on 

less known foods, and contain the latest scientific respiration, which, as the results of Dr. Smith's own 

knowledge respecting them. The present volume is experiments, possess a very high value. We have 

intended to meet this want, and will be found use- not far to go in this work for occasions of favorable 

ful for reference, to both scientific and general criticism ; they occur throughout, but are perhaps 

readers. The author extends the ordinary view of most apparent in those parts of the subject with 

foods, and includes water and air, since they are which Dr. Smith's name is especially linked." — 

important both in their food and sanitary aspects. London Examiner. 

A HAND-BOOK OF CHEMICAL TECHNOLOGY. 

By Rudolph Wagner, Ph. D., Professor of Chemical Technology at the 
University of Wurtzburg. Translated and edited, from the eighth German 
edition, with Extensive Additions, by William Crooks, F. R. S. 
With 336 Illustrations. I vol., 8vo, 761 pp. Cloth, $5. 

Under the head of Metallurgic Chemistry, the latest methods of preparing iron, cobalt, nickel, 
copper, copper-salts, lead and tin and their salts, bismuth, zinc, zinc-salts, cadmium, antimony, 
arsenic, mercury, platinum, silver, gold, manganates, aluminum, and magnesium, are described. 
The various applications of the voltaic current to electro-metallurgy follow under this division. 
The preparation of potash and soda-salts, the manufacture of sulphuric acid, and the recovery of 
sulphur from soda waste, of course occupy prominent places in the consideration of chemical manu- 
factures. It is difficult to overestimate the mercantile value of Mond's process, as well as the 
many new and important applications of bisulphide of carbon. The manufacture of soap will be 
found to include much detail. The technology of glass, stone-ware, limes, and mortars will pre- 
sent much of interest to the builder and engineer. The technology of vegetable fibers has been 
considered to include the preparation of flax, hemp, cotton, as well as paper-making ; while the 
application of vegetable products will be found to include sugar-boiling, wine- and beer-brewing, 
the distillation of spirits, the baking of bread, the preparation of vinegar, the preservation of wood, 
etc. 

Dr. Wagner gives much information in reference to the production of potash from sugar-resi- 
dues. The use of baryta-salts is also fully described, as well as the preparation of sugar from 
beet-roots. Tanning, the preservation of meat, milk, etc., the preparation of phosphorus and ani- 
mal charcoal, are considered as belonging to the technology of animal products. The preparation 
of materials for dyeing has necessarily required much space ; while the final sections of the book 
have been devoted to the technology of heating and illumination. 



34 



D. APPLETON &* CO.'S MEDICAL WORKS. 



A PRACTICAL TREATISE ON THE SURGICAL 
DISEASES OF THE GENITOURINARY ORGANS, including 
Syphilis. Designed as a Manual for Students and Practitioners. With 
Engravings and Cases. By W. H. Van Buren, A. M., M. D., late Profess- 
or of Principles of Surgery, with Diseases of the Genito-Urinary System 
and Clinical Surgery, in Bellevue Hospital Medical College, etc., and E. L. 
Keyes, A. M., M. D., Professor of Dermatology in Bellevue Hospital Medi- 
cal College; Surgeon to the Charity Hospital, Venereal Diseases, etc. 
i vol., 8vo, 672 pp. Cloth, $5; sheep, $6. 

it deals. These facts are largely drawn from 
the extensive and varied experience of the au- 
thors. 

Many important branches of genito-urinary 
diseases, as the cutaneous maladies of the penis 
and scrotum, receive a thorough and exhaustive 
treatment that the professional reader will search 
for elsewhere in vain. 

The subject of syphilis is included, of neces- 
sity, in this treatise. Although properly be- 
longing to the department of Principles of Sur- 
gery, there is no disease falling within the limits 
of this work concerning which clear and correct 
ideas as to nature and treatment will, at the 
present time, so seriously influence success in 
practice. 

The work is elegantly and profusely illus- 
trated, and enriched by fifty-five original cases, 
setting forth obscure and difficult points in diag- 
nosis and treatment. 

' ' The authors ' appear to have succeeded admi- 
rably in giving to the world an exhaustive and re- 
liable treatise on this important class of diseases.' " 
— Northwestern Medical and Surgical Journal. 

" It is a most complete digest of what has long 
been known, and of what has been more recently 
discovered, in the field of syphilitic and genito-urin- 
ary disorders. It is, perhaps, not all exaggeration 
to say that no single work upon the same subject 
has yet appeared, in this or any foreign language, 
which is superior to it." — Chicago Medical Exam- 
iner. 

" The commanding reputation of Dr. Van Buren 
in this specialty, and of the great school and hos- 
pital from which he has drawn his clinical materials, 
together with the general interest which attaches to 
the subject-matter itself, will, we trust, lead very 
many of those for whom it is our office to cater, to 
possess themselves at once of the volume and form 
their own opinions of its merit." — Atlanta Medical 
and Surgical Journal. 




Showing Enlarged Prostate with "Third Lobe," through 
the Base of which a False Passage has been made. 

This work is really a compendium of, and a 
book of reference to, all modern works treating 
in any way of the surgical diseases of the genito- 
urinary organs. At the same time, no other 
single book contains so large an array of original 
facts concerning the class of diseases with which 



A MANUAL OF MIDWIFERY. Including the Pathology 

of Pregnancy and the Puerperal State. By Dr. Carl Schroeder, Professor 
of Midwifery and Director of the Lying-in Institution in the University of 
Erlangen. Translated from the third German edition by Charles H. 
Carter, B. A., M. D., B. S., London, Member of the Royal College of 
Physicians, London. 
With Twenty-six Engravings on Wood. I vol., 8vo, 388 pp. Cloth, $3.50; sheep, $4-5°- 
" The translator feels that no apology is needed in offering to the profession a translation of 
Schroeder's < Manual of Midwifery.' The work is well known in Germany, and extensively used 
as a text-book; it has already reached a third edition within the short space of two years, and it 
is hoped that the present translation will meet the want, long felt in this country, of a manual of 
midwifery embracing the latest scientific researches on the subject." 






D. APPLETON 6- CO.'S MEDICAL WORKS. 



35 



HOSPITALS : Their History, Organization, and Construction. 

Boylston Prize-Essay of Harvard University for 1876. By W. Gill Wylie, 
M. D. 1 vol., 8vo, 240 pp. Cloth, $2.50. 



A TREATISE ON CHEMISTRY. By H. R. Roscoe, 

F. R. S., and C. Schorlemmer, F. R. S., Professors of Chemistry in the 
Victoria University, Owens College, Manchester. Illustrated. 

INORGANIC CHEMISTRY. 8vo. Vol. I : Non-Metallic Elements. $5. 
Vol. II, Part I : Metals. $3. Vol. II, Part II : Metals. $3. 

ORGANIC CHEMISTRY. 8vo. Vol. Ill, Part I : The Chemistry of the 
Hydrocarbons and their Derivatives. $5. Vol. Ill, Part II, com- 
pleting the work : The Chemistry of the Hydrocarbons and their 
Derivatives. $5. 

" It has been the aim of the authors, in writing their present treatise, to place before the read- 
er a fairly complete and yet a clear and succinct statement of the facts of Modern Chemistry, while 
at the same time entering so far into a discussion of chemical theory as the size of the work and the 
present transition state of the science will permit. 

" Special attention has been paid to the accurate description of the more important processes 
in technical chemistry, and to the careful representation of the most approved forms of apparatus 
employed. 

" Much attention has likewise been given to the representation of apparatus adopted for lec- 
ture-room experiment, and the numerous new illustrations required for this purpose have all been 
taken from photographs of apparatus actually in use." — Extract from Preface. 



Specimen of Illustration. 




"The authors are evidently bent on making 
their book the finest systematic treatise on modern 
chemistry in the English language, an aim in which 
they are well seconded by their publishers, who 
spare neither pains nor cost in illustrating and 
otherwise setting forth the work of these distin- 
guished chemists." — London Athenceum. 

" It is difficult to praise too highly the selection 
of materials and their arrangement, or the wealth 
of illustrations which explain and adorn the text. 
In its woodcuts, in its technological details, in its 
historical notices, in its references to original 
memoirs, and, it may be added, in its clear type, 
smooth paper, and ample margins, the volume un- 
der review presents most commendable features. 
Whatever tests of accuracy as to figures and facts 
we have been able to apply have been satisfactorily 

3 



met, while in clearness of statement this volume 
leaves nothing to be desired. Moreover, it is most 
satisfactory to find that the progress of this valuable 
work toward completion is so rapid that its begin- 
ning will not have become antiquated before its end 
has been reached — no uncommon occurrence with 
elaborate treatises on natural science subjects." — 
London Academy. 

" We have no hesitation in saying that this vol- 
ume fully keeps up the reputation gained by those 
that preceded it. There is the same masterly hand- 
ling of the subject-matter ; the same diligent care 
has been bestowed on hunting up all the old history 
connected with each product. It is this that lends 
so great a charm to the whole work, and makes it 
very much more than a mere text-book." — Satur- 
day Review. 



36 



D. APPLETON &* CO.'S MEDICAL WORKS. 



THE BRAIN AND ITS FUNCTIONS. 

Physician to the Hospice de la Salpetriere. 

With Illustrations. i2mo. Cloth, $1.50. 



By J. Luys, 



4 ' No living physiologist is better entitled to 
speak with authority upon the structure and func- 
tions of the brain than Dr. Luys. His studies on 
the anatomy of the nervous system are acknowl- 
edged to be the fullest and most systematic ever un- 
dertaken." — St. 'James's Gazette. 

" It is not too much to say that M. Luys has gone 
further than any other investigator into this great 
field of study, and only those who are at least dimly 
aware of the vast changes going on in the realm of 
psychology can appreciate the importance of his 
revelations. Particularly interesting and valuable 



are the chapters dealing with the genesis and evolu- 
tion of memory, the development of automatic ac- 
tivity, and the development of the notion of person- 
ality." — Boston Evening Traveller. 

" Dr. Luys, at the head of the great French In- 
sane Asylum, is one of the most eminent and suc- 
cessful investigators of cerebral science now living ; 
and he has given unquestionably the clearest and 
most interesting brief account yet made of the 
structure and operations of the brain." — Popular 
Science Monthly. 



GENERAL PHYSIOLOGY OF MUSCLES AND 

NERVES. By Dr. I. Rosenthal, Professor of Physiology at the Univer- 
sity of Erlangen. 

With 75 Woodcuts. i2mo. Cloth, $1.50. 

" Dr. Rosenthal claims that the present work is recondite as to be unprofitable or uninteresting to 
the ' first attempt at a connected account of general the inquiring general reader." — New York Ob- 
physiology of muscles and nerves.' This being the server. 



case, Dr. Rosenthal is entitled to the greatest credit 
for his clear and accurate presentation of the ex- 
perimental data upon which must rest all future 
knowledge of a very important branch of medical 
and electrical science. The book consists of 317 
pages, with seventy-five woodcuts, many of which 
represent physiological apparatus devised by the 
author or by his friends, Professor Du Bois-Rey- 
mond and Helmholtz. It must be regarded as in- 
dispensable to all future courses of medical study." 
— New York Herald. 

"Although this work is written for the instruc- 
tion of students, it is by no means so technical and 



In this volume an attempt is made to give a 
connected account of the general physiology of 
muscles and nerves, a subject which has never be- 
fore had so thorough an exposition in any text- 
book, although it is one which has many points of 
interest for every cultivated man who seeks to be 
well informed on all branches of the science of life. 
This work sets before its readers all, even the most 
intricate, phases of its subject with such clearness of 
expression that any educated person though not a 
specialist can comprehend it." — New Haven Palla- 
dium. 



MEDICAL AND SURGICAL ASPECTS OF IN-KNEE 

(Genu-Valgum) : Its Relation to Rickets ; its Prevention ; and its Treat- 
ment, with or without Surgical Operation. By W. J. Little, M. D., F. R. 
C. P., late Senior Physician to and Lecturer on Medicine at the London 
Hospital; Visiting Physician to the Infant Orphan Asylum at Wanstead; 
the Earlswood Asylum for Idiots ; Founder of the Royal Orthopaedic Hos- 
pital, etc. Assisted by E. Muirhead Little, M. R. C. S. 

One 8vo vol., containing 161 pages, with complete Index, and illustrated by upward of 50 Figures 

and Diagrams. Cloth, $2. 

A DICTIONARY OF MEDICINE, including General 

Pathology, General Therapeutics, Hygiene, and the Diseases peculiar to 

Women and Children. By Various Writers. Edited by Richard Quain, 

M. D., F. R. S., Fellow of the Royal College of Physicians ; Member of the 

Senate of the University of London ; Member of the General Council of 

Medical Education and Registration ; Consulting Physician to the Hospital 

for Consumption and Diseases of the Chest at Brompton, etc. 

In one large 8vo volume of 1,834 pages, and 138 Illustrations. Half morocco, $8. Sold only by 

subscription. 

This work is primarily a Dictionary of Medicine, in which the several diseases are fully dis- 
cussed in alphabetical order. The description of each includes an account of its etiology and ana- 
tomical characters; its symptoms,* course, duration, and termination; its diagnosis, prognosis, 



D. APPLETON &° CO.'S MEDICAL WORKS. 



37 



and, lastly, its treatment. General Pathology comprehends articles on the origin, characters, and 
nature of disease. 

General Therapeutics includes articles on the several classes of remedies, their modes of ac- 
tion, and on the methods of their use. The articles devoted to the subject of Hygiene treat of the 
causes and prevention of disease, of the agencies and laws affecting public health, of the means of 
preserving the health of the individual, of the construction and management of hospitals, and of 
the nursing of the sick. 

Lastly, the diseases peculiar to women and children are discussed under their respective head- 
ings, both in aggregate and in detail. 

Among the leading contributors, whose names at once strike the reader as affording a guaran- 
tee of the value of their contributions, are the following : 



Allbutt, T. Clifford, M. A., M. D. 

Barnes, Robert, M. D. 

Bastian, H. Charlton, M. A., M. D. 

Binz, Carl, M. D. 

Bristowe, J. Syer, M. D. 

Brown-Sequard, C. E., M. D., LL. D. 

Brunton, T. Lauder, M. D., D. Sc. 

Fayrer, Sir Joseph, K. C. S. I., M. D., LL. D. 

Fox, Tilbury, M. D. 

Galton, Captain Douglas, R. E. (retired). 

Gowers, W. R., M. D. 

Wells, T 

" Not only is the work a Dictionary of Medicine 
in its fullest sense ; but it is so encyclopedic in its 
scope that it may be considered a condensed review 
of the entire field of practical medicine. Each sub- 
ject is marked up to date and contains in a nutshell 
the accumulated experience of the leading medical 
men of the day. As a volume for ready reference 
and careful study, it will be found of immense value 
to the general practitioner and student." — Medical 
Record. 

"The 'Medical Dictionary' of Dr. Quain is 
something more than its title would at first indicate. 
It might with equal propriety be called an encyclo- 
paedia. The different diseases are fully discussed in 
alphabetical order. The description of each in- 
cludes an account of its various attributes, often 
covering several pages. Although we have pos- 
sessed the book only the short time since its publica- 
tion, its loss would leave a void we would not know 
how to fill." — Boston Medical and Surg, journal. 

" Although a volume of over 1,800 pages, it is 
truly a mult um in parvo, and will be found of 
much more practical utility than other works which 
might be named extending over many volumes. 
The profession of this country are under obligations 
to you for the republication of the work, and I de- 
sire to congratulate you on the excellence of the 
illustrations, together with the excellent typograph- 
ical execution in all respects." — Austin Flint, 
M. D. 

"It is with great pleasure, indeed, that we an- 
nounce the publication in this country, by the Ap- 
pletons, of this most superb work. Of all the 
medical works which have been, and which will be, 
published this year, the most conspicuous one as 
embodying learning and research — the compilation 
into one great volume, as it were, of the whole sci- 
ence and art of medicine — is the ' Dictionary of 
Medicine ' of Dr. Quain. Ziemen's ' Practice of 
Medicine ' and Reynolds's ' System of Medicine ' 
are distinguished works, forming compilations, in 
the single department of practice, of the labors of 
many very eminent physicians, each one in his con- 
tributions presenting the results of his own observa- 
tions and experiences, as well as those of the inves- 
tigations of others. But in the dictionary of Dr. 
Quain there are embraced not merely the principles 
and practice of medicine in the contributions by the 
various writers of eminence, but general pathology, 
general therapeutics, hygiene, diseases of women 
and children, etc." — Cincinnati Medical News. 

" Criticism in detail we have not attempted, and 
this is in the main because there is not much room 



Greenfield, W. S., M. D. 

Jenner, Sir William, Bart., K. C. B., M. D. 

Legg, J. WlCKHAM, M. D. 

Nightingale, Florence. 
Paget, Sir James, Bart. 
Parkes, Edmund A., M. D. 
Pavy, F. W., M.D. 
Playfair, W. S., M.D. 
Simon, John, C. B., D. C. L. 
Thompson, Sir Henry. 
Waters, A. T. H., M. D. 
Spencer. 

for it. Those who are most competent to pass an 
opinion will, we believe, admit that Dr. Quain has 
carried out a most arduous enterprise with great 
success. His ' Dictionary of Medicine ' embodies 
an enormous amount of information in a most ac- 
cessible form, and it deserves to take its place in the 
library of every medical man as a ready guide and 
safe counselor. Others, too, will find within its 
pages so much information of various kinds that it 
can not fail to establish itself as a standard work of 
reference." — St. James's Budget. 

" Therefore we believe that as a whole the work 
will admirably fulfill its purpose of being a standard 
book of reference until, like other dictionaries of 
progressive science, it will require to be remodeled 
or supplemented to keep pace with advancing 
knowledge." — The Lancet {London). 

"I think 'Quain's Dictionary of Medicine ' an 
excellent work, and of great practical use for every- 
day reference by the physician." — Alexander J. C. 
Skene, M. D., Professor of the Medical and Surgi- 
cal Diseases of Women, Lo?ig Lsland College Hos- 
pital, Brooklyn, N. Y. 

" I regard ' Quain's Dictionary of Medicine' the 
most important, because most useful, publication of 
its kind issued from the medical press for many a 
year. In fact, I know of no similar work that can 
fitly be compared with it. The extraordinary facili- 
ties Dr. Quain possesses, in the choice of distin- 
guished collaborators, have been applied to the con- 
struction of a volume whose contents are so clear 
and compact, yet so full, that the hungriest seeker 
after the latest results of strictly medical research 
can be satisfied at one sitting." — Alexander 
Hutchins, M. D. 

" In this important work the editor has endeav- 
ored to combine two features or purposes : in the 
first place, to offer a dictionary of the technical 
words used in medicine and the collateral sciences, 
and also to present a treatise on systematic medi- 
cine, in which the separate articles on diseases 
should be short monographs by eminent specialists 
in the several branches of medical and surgical sci- 
ence. Especially for the latter purpose, he secured 
the aid of such well-known gentlemen as Charles 
Murchison, John Rose Cormack, Tilbury Fox, 
Thomas Hayden, William Aitken, Charlton Bas- 
tian, Brown-Sequard, Sir William Jenner, Eras- 
mus Wilson, and a host of others. By their aid he 
may fairly be said to have attained his object of 
1 bringing together the latest and most complete in- 
formation, in a form which would allow of ready 
and easy reference."' — Med. and Surg. Reporter. 



38 



D. APPLETON &* CO.'S MEDICAL WORKS. 



A PRACTICAL TREATISE ON THE DISEASES OF 

CHILDREN. Third American from the eighth German edition. Revised 
and enlarged. Illustrated by Six Lithographic Plates. By Alfred 
Vogel, M. D., Professor of Clinical Medicine in the University of Dorpat, 
Russia. Translated and edited by H. Raphael, M. D., late House Sur- 
geon to Bellevue Hospital ; Physician to the Eastern Dispensary for the 
Diseases of Children, etc., etc. 

I vol., 8vo, 640 pp. Cloth, $4.50 ; sheep, $5.50. 

The work is well up to the present state of pathological knowledge ; complete without un- 
necessary prolixity ; its symptomatology accurate, evidently the result of careful observation of a 
competent and experienced clinical practitioner. The diagnosis and differential relations of dis- 
eases to each other are accurately described, and the therapeutics judicious and discriminating. All 
polypharmacy is discarded, and only the remedies which appeared useful to the author commended. 

It contains much that must gain for it the merited praise of all impartial judges, and prove it 
to be an invaluable text-book for the student and practitioner, and a safe and useful guide in the 
difficult but all-important department of Paediatrica. 

THE NEW YORK MEDICAL JOURNAL: A Weekly 
Review of Medicine. Edited by Frank P. Foster, M. D. 

The New York Medical Journal, now in the twenty-second year of its publication, is pub- 
lished every Saturday, each number containing twenty-eight large, double-columned pages of 
reading matter. By reason of the condensed form in which the matter is arranged, it contains 
more reading matter than any other journal of its class in the United States. It is also more 
freely illustrated, and its illustrations are generally better executed, than is the case with other 
weekly journals. 

The special departments of the Journal are as follows : 

LECTURES AND ADDRESSES.— The effort is made to present didactic and clinical 
lectures, each in due proportion, and to give under this head only such lectures as are of interest 
to the great body of the profession. 

ORIGINAL COMMUNICATIONS.— These articles cover the whole range of the medical 
sciences, and include only those that are actually contributed by authors, and those that have 
been read before societies with which the Journal has a special arrangement (including the 
New York Surgical Society, the New York Obstetrical Society, the New York Clinical Society, 
and the Medical Society of the County of Kings). 

CLINICAL REPORTS. — These include reports of interesting cases in hospital practice. 

BOOK NOTICES. — In this department books are noticed strictly in accordance with their 
merits. 

CORRESPONDENCE.— Under this head we include only letters from the regular corre- 
spondents of the Journal, chance communications being given under a separate heading. 

LEADING ARTICLES. — Under this head we class the longer and more formal editorial 
articles. They consist either of resume's of scientific contributions, or of comments on matters of 
interest to the profession as a class, its welfare and its dignity. 

MINOR PARAGRAPHS. NEWS ITEMS. 

OBITUARY NOTES refer for the most part to well-known members of the profession, both 
in this country and abroad. 

LETTERS TO THE EDITOR embrace short communications from others than our regu- 
lar correspondents. 

PROCEEDINGS OF SOCIETIES.— The Journal gives the proceedings of all the lead- 
ing societies, national, State, and local, in a condensed form, but with a degree of fullness com- 
mensurate with their interest to the profession. 

REPORTS ON THE PROGRESS OF MEDICINE include abstracts of the better part 
of current literature, prepared by a staff of gentlemen specially employed for the purpose. 
These reports cover the whole range of medicine. 

MISCELLANY. — Under this head will be found abstracts which it is thought desirable to 
give in advance of the regular time for their appearance in the formal reports, especially Thera- 
peutical Notes, which, published in nearly every number, furnish the reader with the therapeuti- 
cal novelties of the day. 

The volumes begin with January and July of each year. Subscriptions can be arranged to 
begin with the volume. 

Terms, Payable in Advance : One Year, $5.00 ; Six Months, $2.50 ; Single Copy, 12 
cents. (No subscriptions received for less than six months.) Binding Cases, Cloth, 50 cents. 

THE POPULAR SCIENCE MONTHLY and THE NEW YORK MEDICAL JOUR- 
NAL to the same address, $9.00 per annum (full price, $10.00). 



D. APPLETON &» CO:S MEDICAL WORKS. 



39 



ATLAS OF FEMALE PELVIC ANATOMY. By D. 

Berry Hart, M. D., F. R. C. P. E., Lecturer on Midwifery and Diseases 
of Women, School of Medicine, Edinburgh, etc. With Preface by Alex- 
ander J. C. Skene, M. D., Professor of the Medical and Surgical Diseases 
of Women, Long Island College Hospital, Brooklyn, etc. 

Large 4to, 37 Plates with 150 Figures, and 89 pages Descriptive Text. Cloth, $15.00. Sold 

only by subscription. 

"Within recent years much has been done to "As a new work by a well-known author, there 
weed the topographical anatomy of the pelvis of is a natural prejudice in its favor, but this becomes 
numerous errors which have encumbered it. Prom- the more deeply rooted as we constantly get new 
inent among those who have furthered this work is views of old fields, new landmarks for better out- 
the author of the 'Atlas ' now before us, and into looks, new light upon heretofore obscure points, 
this, his latest labor, he has entered with all his ac- In a word, we can, after the most critical study of 
customed vigor. . . . The ' Atlas deserves, and its contents, say with the distinguished editor, Pro- 
will surely have, a wide circulation ; and we are fessor Skene, that ' it is far in advance of any work 
confident that no one will rise from its careful pe- of its kind yet produced.' As such it becomes a 
rusal without having obtained clearer, more accu- necessity for the progressive gynaecologist, for the 
rate, and more intelligent views in regard to the operating surgeon, and for the leading general 
much-vexed questions of female anatomy, or with- practitioner. We congratulate the publishers on 
out having formed a very high opinion of the au- the reproduction of this grand work, and bespeak 
thor's industry, earnestness, and ability." — Edin- for it -a becoming appreciation by the profession of 
burgh Medical Journal. this country." — Medical Record. 

ELEMENTS OF PRACTICAL MEDICINE. By Alfred 

H. Carter, M. D., Member of the Royal College of Physicians, London ; 
Physician to the Queen's Hospital, Birmingham, etc. 

Third edition, revised and enlarged. I vol., i2mo, 427 pages. Cloth, $3.00. 

"Although this work does not profess to be a wisely, perhaps, since we know so little about it ; 

complete treatise on the practice of medicine, it is and of that other almost unknown quantity in 

too full to be called a compend ; it is rather an in- medicine, scrofula, the author has with equal pru- 

troduction to the more exhaustive study embodied dence abstained from saying much. He admits 

in the larger text-books. An idea of the degree to such a condition as scrofulosis, but thinks it has no 

which condensation has been carried in it can be necessary connection with tuberculosis. He is a 

gathered from the statement that but twenty-one believer in the germ-theory of disease, and speaks 

pages are occupied with the diseases of the circula- of Koch's investigations and discoveries as very im- 

tory system. If the reader gets the impression that portant, to him almost conclusive, 

the physical signs are given somewhat too meager- " Notwithstanding the condensed make-up of 

ly, it is to be said that, by way of compensation, the book, it is quite comprehensive, including even 

the symptomatolbgy in general is considered with cutaneous and venereal diseases. It contains much 

admirable perspicuity and good judgment. valuable information, and we may add that it is 

" Leucocythajmia is dismissed with one page — very readable." — New York Medical Journal. 

THE MINERAL SPRINGS OF THE UNITED STATES 

AND CANADA, with Analysis and Notes on the Prominent Spas of 

Europe and a List of Sea-side Resorts. An enlarged and revised edition. 

By George E. Walton, M. D., Lecturer on Materia Medica in the Miami 

Medical College, Cincinnati. 

Second edition, revised and enlarged. I vol., i2mo, 414 pp. With Maps. $2. 

The author has given the analysis of all the springs in this country and those of the principal 
European spas, reduced to a uniform standard of one wine-pint, so that they may readily be com- 
pared. He has arranged the springs of America and Europe in seven distinct classes, and de- 
scribed the diseases to which mineral waters are adapted, with references to the class of waters 
applicable to the treatment ; and the peculiar characteristics of each spring as near as known are 
given — also the location, mode of access, and post-office address of every spring are mentioned. 
In addition, he has described the various kinds of baths and the appropriate use of them in the 
treatment of disease. 

' ' Precise and comprehensive, presenting not only use as intelligently and beneficially as they can other 
reliable analysis of the waters, but their therapeutic valuable alterative agents." — Sanitarian. 
value, so that physicians can hereafter advise their 



4Q 



D. APPLETON &* CO.S MEDICAL WORKS. 



DISEASES OF MEMORY : An Essay in the Positive Psy- 
chology. By Th. Ribot, Author of " Heredity," etc. Translated from the 
French by William Huntington Smith. 

i2mo. Cloth, $1.50. 



' ' Not merely to scientific, but to all thinking 
men, this volume will prove intensely interesting." 
— New York Observer. 

"M. Ribot has bestowed the most painstaking 
attention upon his theme, and numerous examples 
of the conditions considered greatly increase the 
value and interest of the volume." — Philadelphia 
North America7i. 

" 'Memory,' says M. Ribot, 'is a general func- 
tion of the nervous system. It is based upon the 
faculty possessed by the nervous elements of con- 
serving a received modification, and of forming as- 
sociations.' And again : ' Memory is a biological 
fact. A rich and extensive memory is not a collec- 
tion of impressions, but an accumulation of dynam- 



ical associations, very stable and very responsive to 
proper stimuli. . . . The brain is like a laboratory 
full of movement where thousands of operations are 
going on all at once. Unconscious cerebration, not 
being subject to restrictions of time, operating, so to 
speak, only in space, may act in several directions 
at the same moment. Consciousness is the narrow 
gate through which a very small part of all this 
work is able to reach us.' M. Ribot thus reduces 
diseases of memory to law, and his treatise is of ex- 
traordinary interest." — Philadelphia Press. 

" It is not too much to say that in no single work 
have so many curious cases been brought together 
and interpreted in a scientific manner." — Boston 
Evening Traveller. 



A TREATISE ON INSANITY, in its Medical Relations. 

By William A. Hammond, M. D., Surgeon-General U. S. Army (retired 
list) ; Professor of Diseases of the Mind and Nervous System, in the New- 
York Post-Graduate Medical School ; President of the American Neuro- 
logical Association, etc. 

1 vol., 8vo, 767 pp. Cloth, $5; sheep, $6. 

In this work the author has not only considered the subject of Insanity, but has prefixed that 
division of his work with a general view of the mind and the several categories of mental faculties, 
and a full account of the various causes that exercise an influence over mental derangement, such 
as habit, age, sex, hereditary tendency, constitution, temperament, instinct, sleep, dreams, and 
many other factors. 

Insanity, it is believed, is in this volume brought before the reader in an original manner, and 
with a degree of thoroughness which can not but lead to important results in the study of psycho- 
logical medicine. Those forms which have only been incidentally alluded to or entirely disregard- 
ed in the text-books hitherto published are here shown to be of the greatest interest to the general 
practitioner and student of mental science, both from a normal and abnormal stand-point. To a 
great extent the work relates to those species of mental derangement which are not seen within 
asylum walls, and which, therefore, are of special importance to the non-asylum physician. 
Moreover, it points out the symptoms of Insanity in its first stages, during which there is most 
hope of successful medical treatment, and before the idea of an asylum has occurred to the patient's 
friends. 

commending the book to the medical profession, as 
it is to them it is specially addressed." — Therapeutic 
Gazette. 



" We believe we may fairly say that the volume 
is a sound and practical treatise on the subject with 
which it deals ; contains a great deal of information 
carefully selected and put together in a pleasant and 
readable form ; and, emanating, as it does, from an 
author whose previous works have met with a most 
favorable reception, will, we have little doubt, obtain 
a wide circulation." — The Dublin Journal of Medi- 
cal Science. 

"... The times are ripe for a new work on in- 
sanity, and Dr. Hammond's great work will serve 
hereafter to mark an era in the history of American 
psychiatry. It should be in the hands of every 
physician who wishes to have an understanding of 
the present status of this advancing science. Who 
begins to read it will need no urging to continue ; 
he will be carried along irresistibly. We unhesitat- 
ingly pronounce it one of the best works on insan- 
ity which has yet appeared in the English language." 
r— American Journal of the Medical Sciences. 

" Dr. Hammond is a bold and strong writer, has 
given much study to his subject, and expresses him- 
self so as to be understood by the reader, even if the 
latter does not coincide with him. We like the book 
very much, and consider it a valuable addition to the 
literature of insanity. We have no hesitancy in 



"Dr. Hammond has added another great work 
to the long list of valuable publications which have 
placed him among the foremost neurologists and 
alienists of America ; and we predict for this volume 
the happy fortune of its predecessors — a rapid jour- 
ney through paying editions. We are sorry that our 
limits will not permit of an analysis of this work, 
the best text-book on insanity that has yet appeared." 
— The Polyclinic. 

' ' We are ready to welcome the present volume 
as the most lucid, comprehensive, and practical ex- 
position on insanity that has been issued in this 
country by an American alienist, and furthermore, 
it is the most instructive and assimilable that can be 
placed at present in the hands of the student unini- 
tiated in psychiatry. The instruction contained 
within its pages is a food thoroughly prepared for 
mental digestion : rich in the condiments that stimu- 
late the appetite for learning, and substantial in the 
more solid elements that enlarge and strengthen the 
intellect." — New Orleans Medical and Surgical 
Journal. 



D. APPLETON &> CO.'S MEDICAL WORKS, 4I 

THE POPULAR SCIENCE MONTHLY. Conducted by 

E. L. and W. J. Youmans. 

The volumes begin in May and November of each year. Subscriptions may begin at any time. 
Terms, $5 per annum ; single number, 50 cents. 

"The Popular Science Monthly" and "New York Medical Journal" to one address, $9 per 
annum (full price, $10). 

" The Popular Science Monthly " was established a dozen years ago to bring before the general 
public the results of scientific thought on many large and important questions which could find no 
expression in the current periodicals. Scientific inquiry was penetrating many new fields, extend- 
ing important knowledge, and profoundly affecting opinion upon numberless questions of specula- 
tive and practical interest. It was the policy of this magazine at the outset, and has been con- 
stantly adhered to since, to obtain the ablest statements from the most distinguished scientific men 
of all countries in their bearing upon the higher problems of investigation. Leaving the dry and 
technical details of science, which are of chief concern to specialists, to the journals devoted to 
them, " The Popular Science Monthly " has dealt with those more general and practical subjects 
which are of the greatest interest and importance to the people at large. 

That which was at first a dubious experiment has now become an assured and permanent suc- 
cess. Our " Monthly " is the acknowledged organ of progressive scientific ideas in this country. 
Received with favor at the outset, it has gone on increasing in circulation and in influence, until its 
power is felt and acknowledged in the highest departments of intellectual activity, and its leader- 
ship is recognized in the great work of liberalizing and educating the popular mind. 

Making neither sensational appeals nor flaring announcements, we may now refer to its course 
in the past as a sufficient guarantee that it will continue to discuss in the same earnest and fearless, 
but always respectful manner, the various important questions falling within its scope that are en- 
titled to the intelligent consideration of thinking people. The twenty-three volumes now published 
constitute the best library of advanced scientific knowledge to be found in any country, and each 
new volume is certain to prove of increasing interest and value. 

Science is the great agency of improvement in this age, private and public, individual, social, 
professional, and industrial. In its irresistible progress it touches everywhere, and affects every- 
body. It gives law to the material interests of the community, and modifies its ideas, opinions, 
and beliefs, so that all have an interest in being informed of its advancement. Those, therefore, 
who desire to know what is going on in the world of thought in these stirring times, when new 
knowledge is rapidly extending, and old errors are giving way, will find that they can keep informed 
only by subscribing for " The Popular Science Monthly." 

" This is one of the very best periodicals of its to persons of literary tastes who have neither time 
kind published in the world. Its corps of contribu- nor opportunity to prosecute special scientific re- 
tors comprise many of the ablest minds known to searches, but who, nevertheless, wish to have a cor- 
science and literature." — American Medical your- rect understanding of what is being done by others 
nal (St. Louis). in the various departments of science." — Louisia?ia 

" No scientific student can dispense with this *' 
monthly, and it is difficult to understand how any " A journal of eminent value to the cause of 

one making literary pretensions fails to become a popular education in this country." — New York 

regular reader of this journal. ' The Popular Sci- Tribune. 

ence Monthly ' meets a want of the medical profes- ,. „ , . . , . 1 . i , ,, . ... . 

sion not otherwise met. It keeps full pace with the . . Every physician s table should bear this valu- 

progress of the times in all the departments of sci- able monthly, which we believe to be one of the 

entitle pursuit. "- Virginia Medical Monthly. most m ^ r ! stmg a " d in structiye of the periodicals 

now published, and one which is destined to play a 

" Outside of medical journals, there is no peri- large part in the mental development of the laity of 

odical published in America as well worthy of being this country." — Canadian Journal of Medical Sci- 

placed upon the physician's library -table and regu- ence. 
larly read by him as " The Popular Science Month- ..r^,. . . ... . A . u . ,, . 

ly/»-St. Louis Clinical Record. . + This magazine is worth its weight m gold, for 

J its service m educating the people. — American 

" ' The Popular Science Monthly ' is invaluable Journal of Education (St. Louis). 

DISEASES OF THE OVARIES: Their Diagnosis and 

Treatment. By T. Spencer Wells, Fellow and Member of Council of 

the Royal College of Surgeons of England, etc., etc. 

1 vol., 8vo, 478 pp. Illustrated. Cloth, $4.50. 

In 1865 the author issued a volume containing reports of one hundred and fourteen cases of 
Ovariotomy, which was little more than a simple record of facts. The book was soon out of print, 
and, though repeatedly asked for a new edition, the author was unable to do more than prepare 
papers for the Royal Medical and Chirurgical Society, as series after series of a hundred cases ac- 
cumulated. On the completion of five hundred cases, he embodied the results in the present vol- 
ume, an entirely new work, for the student and practitioner, and trusts it may prove acceptable to 
them and useful to suffering women. 



42 



D. APPLETON 6- CO.'S MEDICAL WORKS. 



LECTURES ON THE PRINCIPLES OF SURGERY. 

Delivered at the Bellevue Hospital Medical College. By the late W. H. 
Van Buren, M. D., LL. D. Edited by Dr. Lewis A. Stimson. 
i vol., 8vo, 588 pages. Cloth, $4.00 ; sheep, $5.00. 



"The name of the author is enough. The book 
will sell. The lectures are good." — Denver Medi- 
cal Times. 

" If we are to judge of the interesting style by 
the mere reading of these lectures, how greatly they 
must have been appreciated by those who heard 
them by the teacher ! There is nothing dry or prosy 
in them. The illustrations of principles are drawn 
from the clinical material of the teacher, and are 
always fresh and a, propos. Past and present theo- 
ries are compared in such a way as to give the stu- 
dent an interest in the work of older pathologists, 
and to point out progress made, without wearying 



him with a dry narration at a time when he is not 
able to comprehend the underlying philosophy. 

"Dr. Van Buren's popularity as a teacher can 
be easily understood from a study of this volume. 
His manner is vivacious, his matter select, and his 
fullness of knowledge easily discernible. He writes 
like one in authority, full of enthusiasm, and pos- 
sessed of the skill of imparting to students just that 
sort of knowledge best suited to their future intel- 
lectual growth. 

"The work is handsomely printed, with full- 
faced, clear type and leaded lines, and is in every 
way a credit to the publishers." — North Carolina 
Medical Journal. 



OSTEOTOMY AND OSTEOCLASIS, for the Correction of 
Deformities of the Lower Limbs. By Charles T. Poore, M. D., Surgeon 
to St. Mary's Free Hospital for Children, New York. 

1 vol., 8vo, 202 pages, with 50 Illustrations. Cloth, $2.50. 





"This handsome and carefully-prepared mono- 
graph treats of osteotomy as applied to the repair 
of genu valgum, genu varum, anchylosis of the 
knee-joint, deformities of the hip-joint, and for 
curves of the tibia. The author has enjoyed large 
opportunities to study these special malformations 
in the hospitals to which he is attached, and de- 
scribes the operations from an ample observation. 
Quite a number of well-engraved illustrations add 
to the value of the volume, and an exhaustive bib- 
liography appended enables the reader to pursue 
any topic in which he may be interested into the 
productions of other writers." — Medical and Sur- 
gical Reporter. 

" Dr. Poore, who has already become so well 
known by journal articles on bone surgery, has con- 



densed his experience in the work before us. He 
has succeeded in doing this in a very satisfactory 
way. We can not too strongly commend the clear 
and succinct manner in which the author weighs 
the indications for treatment in particular cases. 
In so doing he shows a knowledge of his subject 
which is as extensive as it is profound, and no one 
at all interested in orthopedy can read his conclu- 
sions without profit. His own cases, which are 
carefully reported, are valuable additions to the lit- 
erature of the subject. These, together with oth- 
ers, which are only summarized, contain so much 
practical information and sound surgery that they 
give a special value to the work, altogether inde- 
pendent of its other excellences. It is a good book 
in every way, and we congratulate the author ac- 
cordingly." — Medical Record. 



D. APPLETON &> CO.'S MEDICAL WORKS. 



43 



A TREATISE ON BRAIN-EXHAUSTION, with some 

Preliminary Considerations on Cerebral Dynamics. By J. Leonard Corn- 
ing, M. D., formerly Resident Assistant Physician to the Hudson River 
State Hospital for the Insane ; Member of the Medical Society of the 
County of New York, of the Physicians' Mutual Aid Association, of the 
New York Neurological Society, of the New York Medico-Legal Society, 
of the Society of Medical Jurisprudence ; Physician to the New York Neu- 
rological Infirmary, etc. ; Member of the New York Academy of Medicine. 

Crown 8vo. Cloth, $2.00. 



" Dr. Coming's neat little volume has the merit 
of being highly suggestive, and, besides, is better 
adapted to popular reading than any other profes- 
sional work on the subject that we know of." — Pa- 
cific Medical and Surgical Journal. 

" This is a capital little work on the subject 
upon which it treats, and the author has presented, 
from as real a scientific stand-point as possible, a 
group of symptoms, the importance of which is 
sufficiently evident. To fully comprehend the ideas 
as presented by the author, the whole book should 
be read ; and, as it consists of only 234 pages, the 
task would not be a severe or tedious one, and the 
information or knowledge obtained would be much 
more than equivalent for the time spent and cost 
of book included. Literary men and women would 
do well to procure it." — Therapeutic Gazette. 



" This book belongs to a class that is more and 
more demanded by the cultured intelligence of the 
period in which we live. Dr. Corning may be 
ranked with Hammond, Beard, Mitchell, and 
Crothers, of this country, and with Winslow, An- 
stie, Thompson, and more recent authors of Great 
Britain, in discussing the problems of mental dis- 
turbance, in a style that makes it not only profit- 
able but attractive reading for the student of psy- 
chology. The author has divided the work into 
short chapters, under general headings, which are 
again subdivided into topics, that are paragraphed 
in a concise and definite form, which at once strikes 
the careful reader as characteristic of a method that 
is terse, concise, and readily apprehended. There 
are twenty-eight of these pithy chapters, which no 
student of mental diseases can fail to read without 
loss." — American Psychological Journal. 



PRACTICAL MANUAL OF DISEASES OF WOMEN 

AND UTERINE THERAPEUTICS. For Students and Practitioners. 
By H. Macnaughton Jones, M. D., F. R. C. S. I. and E., Examiner in 
Obstetrics, Royal University of Ireland ; Fellow of the Academy of Medi- 
cine in Ireland ; and of the Obstetrical Society of London, etc. 

1 vol., i2mo. 410 pages. 188 Illustrations. Cloth, $3 co. 



"As a concise, well-written, useful manual, we 
consider this one of the best we have ever seen. 
The author, in the preface, tells us that ' this book 
is simply intended as a practitioner's and student's 
manual. I have endeavored to make it as practical 
in its teachings as possible. ' The style is pleasant 
to peruse. The author expresses his ideas in a clear 
manner, and it is well up with the approved meth- 
ods and treatment of the day. It is well illustrated, 
and due credit is given to American gynaecologists 
for work done. It is a good book, well printed in 
good, large type, and well bound." — New England 
Medical Monthly. 

" It is seldom that we see a book so completely 
fill its avowed mission as does the one before us. 
It is practical from beginning to end, and can not 
fail to be appreciated by the readers for whom it is 
intended. The author's style is terse and perspicu- 
ous, and he has the enviable faculty of giving the 
learner a clear insight of his methods and reasons 
for treatment. Prepared for the practitioner, this 
little work deals only with his every-day wants in 
ordinary family practice. Every one is compelled 
to treat uterine disease who does any general busi- 
ness whatever, and should become acquainted with 
the minor operations thereto pertaining. The book 



before us covers this ground completely, and we 
have nothing to offer in the way of criticism." — 
Medical Record. 

" The manual before us is not the work of a spe- 
cialist — using this term in a narrow sense — but of 
an author already favorably known to the students 
of current medical literature by various and com- 
prehensive works upon other branches of his profes- 
sion. Nor is it, on the other hand, the work of an 
amateur or merely ingenious collaborateur, for Dr. 
Macnaughton Jones's gynaecological experience in 
connection with the Cork Hospital for Women and 
the Cork Maternity was such as fairly entitles him 
to speak authoritatively upon the subjects with 
which it deals. But, after so many works by avowed 
specialists, we are glad to welcome one upon Gynae- 
cology by an author whose opportunities and energy- 
have enabled him to master the details of so many 
branches of medicine. We are glad also to be able 
to state that his work compares very favorably with 
others of the same kind, and that it does admirably 
fulfill the purposes with which it was written — ' as 
a safe guide in practice to the practitioner, and an 
assistance in the study of this branch of his profes- 
sion to the student.'" — Dublin Journal of Medical 
Science. 



44 



D. APPLETON 6- CO.'S MEDICAL WORKS. 



A HAND-BOOK OF THE DISEASES OF THE EYE, 

AND THEIR TREATMENT. By Henry R. Swanzy, A. M., M. B., 
F. R. C. S. L, Surgeon to the National Eye and Ear Infirmary ; Ophthalmic 
Surgeon to the Adelaide Hospital, Dublin. 

Crown 8vo, 437 pages. With 122 Illustrations, and Holmgren's Tests for Color-Blindness. 

Cloth, $3.00. 



" Though, amid the numerous recent text-books 
on eye-diseases, there would appear to be little 
room or necessity for another, we must admit that 
this one justifies its presence, by its admirable type, 
illustrations, and dress, by its clear wording, and, 
above all, by the vast amount of varied matter 
which it embraces within the relatively small com- 
pass of some four hundred pages. The author has 
omitted — and, in our opinion, with perfect wis- 
dom — the usual collection of indifferent, second- 
hand ophthalmoscopic plates. So, also, he has not 
included test-types, though he has appended, for 
explanatory purposes, the fan which is often used 
in astigmatism. Admirable samples of the colored 
wools, used in Holmgren's tests, are sewn into the 
cover, and, by aid of these, it will be perfectly within 



the power of any one, wherever residing, to make a 
proper collection of colored wools and tests for the 
qualitative estimation of congenital color-defects. 
We have criticised the book at length, and drawn at- 
tention freely to points on which the author's opin- 
ion is at variance with the commonly received teach- 
ing. This we have done because there is much 
individuality in the work, which bears every mark 
of having been well thought out and independently 
written. In these respects it presents a marked su- 
periority over the ordinary run of medical hand- 
books ; and we have no hesitation in recommending 
it to students and young practitioners as one of the 
very best, if not actually the best, work to procure 
on the subject of ophthalmology." — British Medi- 
cal Journal. 



DISEASES OF THE HEART AND THORACIC AOR- 
TA. By Byrom Bramwell, M. D., F. R. C. P. E., Lecturer on the Prin- 
ciples and Practice of Medicine and on Medical Diagnosis in the Extra- 
Academical School of Medicine, Edinburgh ; Pathologist to the Royal 
Infirmary, Edinburgh, etc. 

Illustrated with 226 Wood Engravings and 68 Lithograph Plates, showing 91 Figures — in all, 
317 Illustrations. 1 vol., 8vo, 783 pages. Cloth, $8.00 ; sheep, $9.00. 

" A careful perusal of this work will well repay 
the student and refresh the memory of the busy 
practitioner. It is the outcome of sound knowledge 
and solid work, and thus devoid of all ' padding,' 
which forms the bulk of many monographs on this 
and other subjects. The material is treated with 
due regard to its proportionate importance, and the 
author has well and wisely carried out his apparent 
intention of rather furnishing a groundwork of 
knowledge on which the reader must build for him- 
self by personal observation, than of making excur- 
sions into the region of dogma and of fancy by 
which his book might have secured a perhaps more 
rapid but certainly a more evanescent success than 
that which it will now undoubtedly and deservedly 
attain." — Medical Times and Gazette. 



"In this elegant and profusely illustrated vol- 
ume Dr. Bramwell has entered a field which has 
hitherto been so worthily occupied by British au- 
thors — Hope, Hayden, Walshe, and others ; and 



we can not but admire the industry and care which 
he has bestowed upon the work. As it stands, it 
may fairly be taken as representing the stand-point 
at which we have arrived in cardiac physiology and 
pathology ; for the book opens with an extended 
account of physiological facts, and especially the 
advances made of late years in the neuro-muscular 
mechanism of the heart and blood-vessels. Al- 
though in this respect physiological research has 
outstripped clinical and pathological observation, 
Dr. Bramwell has, we think, done wisely in so in- 
troducing his treatise, and has thereby greatly add- 
ed to its value. A chapter upon thoracic aneurism 
terminates a work which, from the scientific man- 
ner in which the subject is treated, from the care 
and discrimination exhibited, and the copious elab- 
orate illustrations with which it is adorned, is one 
which will advance the author's reputation as a 
most industrious and painstaking clinical observer." 
— Lancet. 



THE ESSENTIALS OF ANATOMY, PHYSIOLOGY, 

AND HYGIENE. By Roger S. Tracy, M. D., Sanitary Inspector of 

the New York City Health Department. 

i2mo. Cloth, $1.25. 

This work has been prepared in response to the demand for a thoroughly scientific and yet 
practical text-book for schools and academies, which shall afford an accurate knowledge of the 
essential facts of Anatomy and Physiology, as furnishing a scientific basis for the study of 
Hygiene and the Laws of Health. It also treats, in a rational manner, of the physiological effects 
of alcohol and other narcotics, fulfilling all the requirements of recent legislative enactments upon 
this subject. 



D. APPLETON &* CCS MEDICAL WORKS. 



45 



THE RELATION OF ANIMAL DISEASES TO THE 

PUBLIC HEALTH, and their Prevention : With a Brief Historical 
Sketch of the Development of Veterinary Medicine, from the Earliest Ages 
to the Present Time ; and a Critical Historical Sketch of the Leading 
Schools of the World, showing the Reasons which led to their Foundation, 
and with the Endeavor to draw from their Experiences Teachings of Value 
toward the Establishment of a General Veterinary Police-hygienic System 
and Veterinary Schools in this Country. By Frank S. Billings, Veteri- 
nary Surgeon, Graduate of the Royal Veterinary Institute, Berlin ; Mem- 
ber of the Royal Veterinary Association of the Province of Brandenburg, 
Prussia ; Honorary Member of the Veterinary Society of Montreal, Can- 
ada, etc., etc. 

I vol., 8vo. Cloth, $4.00. 

" This is the great health-book of Dr. Frank S. least should be in the libraries of every national, 
Billing's, and it is not too much to promise that a State, city, town, and county Board of Health. It 
study and observance of its teachings, that are the certainly should be studied by every teacher and 
results of actual experiments, will work a revolution scientific practitioner of veterinary medicine, and 
in the sanitary condition of the United States. . . . will be of great service to every great stock and cat- 
It is a work for all stock-breeders and for all fami- tie holder and dealer. ... It is evidently written 
lies." — Louisville Courier-Journal. by a man of great ability and high culture, well 

..„, . . ., ,.., r , . . . . .... versed both in the literature and science as well as 

'This is the title of a work jus pven to the fa . ^ b ^ f ^ subject> Such maQ 

wor Id and in its pages subjects of vital interest are has £ at and ina f ienab i e right to have opinions 

treated of in a lucid and perspicuous manner. . . M * and he hag th & nd does not £ esitate 

These well-established statements should arouse the express them. ... We hope and believe that 

public feeling to provide that boards of health ^ ^ be receiyed ^ h 

should be careful and efficient m the exercise of by those especially attacked, with the great welcome 

their duties, as also that as individuals every one * . ^ &nd blishers must Expect for it. 

should labor to take good care of himself his f am- j ^ ^ . stand alongside of the popular trea- 

ily, and his domestic ammals."-^ York Times. ^ of Hmiard and Rob g ertsoI1) and ^/ all purely 

" This handsome volume does great credit to its scientific matters will lead them. Either of these 
author and publishers. It is an excellent book in works, together with Dr. Billings's, will make al- 
most respects, an extraordinary one in many, and most a complete library on veterinary medicine." — 
an objectionable one in very few. It at the very Journal 0/ Comparative Medicine and Surgery. 

PYURIA; or, PUS IN THE URINE, AND ITS TREAT- 

MENT : Comprising the Diagnosis and Treatment of Acute and Chronic 
Urethritis, Prostatitis, Cystitis, and Pyelitis, with especial reference to their 
Local Treatment. By Dr. Robert Ultzmann, Professor of Genito-Uri- 
nary Diseases in the Vienna Poliklinik. Translated, bv permission, by Dr. 
Walter B. Platt, F. R. C. S. (Eng.), Baltimore. 

i2mo. Cloth, $1.00. 

" Those of the profession who are familiar with but also for the many practical suggestions regard- 

the works of Professor Ultzmann will welcome this ing treatment to be found in the chapter on Thera- 

translation as constituting a real addition to our lit- peutics. The translator is to be congratulated upon 

erature on genito-urinary diseases. It can not be the excellent manner in which his work has been 

too highly recommended to the attention of the pro- accomplished. The book is neatly and tastefully got 

fession, not only on account of its scientific value, up by the publishers." — Maryland Med. Journal. 

HAND-BOOK OF SANITARY INFORMATION FOR 

HOUSEHOLDERS. Containing Facts and Suggestions about Ventila- 
tion, Drainage, Care of Contagious Diseases, Disinfection, Food, and 
Water. With Appendices on Disinfectants and Plumbers' Materials. By 
Roger S. Tracy, M. D., Sanitary Inspector of the New York City Health 

Department. 

i6mo. Cloth, 50 cents. 



4 6 



D. APPLETON &> CO.'S MEDICAL WORKS. 



A TREATISE ON NERVOUS DISEASES: Their Symp- 

toms and Treatment. A Text-book for Students and Practitioners. By S. 
G. Webber, M. D., Clinical Instructor in Nervous Diseases, Harvard Med- 
ical School ; Visiting Physician for Diseases of the Nervous System at the 
Boston City Hospital, etc. 

I vol., 8vo, 415 pp. 15 Illustrations. Cloth, $3.00. 

peculiar language of the more advanced neurologist. 
He covers very completely the field of nervous affec- 
tions, and his book will prove a very valuable acqui- 
sition to the library of the intelligent physician." — 
Medical Age. 

" The beauty and usefulness of the book are much 
enhanced by the fact that it is not loaded down with 
references to other authors, but proceeds in an orig- 
inal manner to sum up all that is known to the 
present day upon the subjects treated. Taking the 
book as a whole it is one of the best we have seen 
in many a day." — Texas Courier-Record. 



" The book before us is especially adapted to the 
needs of the general practitioner who, though con- 
scious of his inability to discern and trace the nerv- 
ous element in the cases under his care, realizes 
very fully that this inability is not consonant with 
the best interests of his patient. Dr. Webber has 
not written for the specialist, but for the student 
and general practitioner, who will find in his book 
what they most need for the diagnosis and treat- 
ment of the diseases as they present themselves in 
general practice. His style is very readable and 
lucid, and is well adapted to those who have not 
specially prepared themselves to understand the 



THE CURABILITY AND TREATMENT OF PUL- 
MONARY PHTHISIS. By S. Jaccoud, Professor of Medical Pathology 
to the Faculty of Paris ; Member of the Academy of Medicine ; Physician 
to the Lariboisiere Hospital, Paris, etc. Translated and edited by Montagu 
Lubbock, M. D. (London and Paris), M. R. C. P. (England), etc. 
8vo, 407 pp. Cloth, $4.00. 



" This is the work of that most eminent French- 
man of the Ecole de Medecine of Paris, and the 
translation of Lubbock is strong and masterly inas- 
much as it evidences the possession of a large 
vocabulary knowledge of both the original and 
English. No man of the present day, with the 
single exception perhaps of Hughes Rennet, has 
devoted as much careful study to the climatic treat- 
ment of phthisis as Dr. Jaccoud, and his conclusions 
on this point so far as regards the Continent of 
Europe must be deemed final." — Cincinnati Lancet 
and Clinic. 



" M. Jaccoud, the author of the work, and the 
eminent professor of the Ecole de Medecine, Paris, 
is generally recognized on the Continent as one of 
the best authorities on pulmonary phthisis, so that 
an English edition of his work will certainly be 
very acceptable to those interested in the subject. 
. . . M. Jaccoud's reputation is justly so great that 
his opinions with respect to the treatment will be 
read with general interest." — Texas Courier- Record 
of Medicine. 



THE USE OF THE MICROSCOPE IN CLINICAL 

AND PATHOLOGICAL EXAMINATIONS. By Dr. Carl Friedlaen- 
der, Privat-Docent in Pathological Anatomy in Berlin. Translated from 
the enlarged and improved second edition, by Henry C. Coe, M. D., etc. 
With a Chromo-Lithograph. l2mo, 195 pp., with copious Index. Cloth, $1.00. 



" We are very much pleased to see Dr. Fried- 
laender's little book make its appearance in English 
dress. As we have a practical acquaintance of the 
German edition since its appearance, we can speak 
of it in terms of unqualified praise. . . . Every one 
doing pathological work should have this little book 
in his possession. . . . The translator has done his 
work well, and has certainly conferred a great favor 
on all microscopists by placing within the reach of 
every one the work of so accomplished a teacher as 
Dr. Carl Friedlaender." — Canada Medical and Sur- 
gical Journal. 



1 ' Much good has been done in placing this little 
work in the hands of the profession. The technique 
of preparing, cutting, and staining specimens is 
given at some length ; also rules for the examination 
of the. various bodily fluids in both health and 
disease. The use of the microscope with high pow- 
ers, immersion lenses, and other accessories, is ex- 
plained very clearly. It is a very readable volume, 
even for those not engaged in actual laboratory 
work. A chromo-lithograph shows the various 
forms of disease-germs which have been definitely 
isolated." — Medical Record. 



MEDICAL ETHICS AND ETIQUETTE. Commentaries 
on the National Code of Ethics. By Austin Flint, M. D. 
i2mo, 101 pp. 60 cents. 



D. APPLE TON &* CO:S MEDICAL WORKS. 



47 



A MANUAL OF DERMATOLOGY. By A R. Robinson, 

M. B., L. R. C. P. and S. (Edinburgh), Professor of Dermatology at the 
New York Polyclinic ; Professor of Histology and Pathological Anatomy at 
the Woman's Medical College of the New York Infirmary. Revised and 
corrected. 

8vo, 647 pp. Cloth, $5.00. 



"It includes so much good, original work, and 
so well illustrates the best practical teachings of the 
subject by our most advanced men, that I regard it 
as commanding at once a place in the very front 
rank of all authorities. . . . "—James Nevins 
Hyde, M. D. 

" Dr. Robinson's experience has amply qualified 
him for the task which he assumed, and he has given 
us a book which commends itself to the considera- 
tion of the general practitioner." — Medical Age. 



" In general appearance it is similar to Duhring's 
excellent book, more valuable, however, in that it 
contains much later views, and also on account of 
the excellence of the anatomical description accom- 
panying the microscopical appearances of the diseases 
spoken of." — St. Louts Med. and Surg. Journal. 

1 ' Altogether it is an excellent work, helpful to 
every one who consults its pages for aid in the study 
of skin-diseases. No physican who studies it will 
regret the placing of it in his library." — Detroit 
Lancet. 



AN ATLAS OF CLINICAL MICROSCOPY. By Alex- 
ander Peyer, M. D. Translated and edited by Alfred C. Girard, M. D., 
Assistant Surgeon United States Army. First American, from the manu- 
script of the second German edition, with Additions. 
90 Plates, with 105 Illustrations, Chromo-Lithographs. Square 8vo. Cloth, $6.00. 



"All who are interested in clinical microscopy 
will be pleased with the design and execution of this 
work, and will feel under obligation to the author, 
translator, and publishers for placing so valuable a 
work in their hands. The plates in which are figured 
the various urinary inorganic deposits are especially 
fine, and the various forms of tube-casts, hyaline, 
waxy, epithelial, and mucous, are depicted with great 
fidelity and accuracy." — Philadelphia Med. Times. 

" To those students and practitioners of medicine 
who are interested in microscopical work and who 



are familiar with the use of this valuable aid to hu- 
man vision in the study of nature, the present work 
will prove of incalculable value, since it represents 
the original work of an accomplished microscopist 
and artist. Accompanying the plates is a text of 
explanatory notes showing the various methods of 
working with the microscope and the significance of 
what is observed. The plates have been most 
handsomely printed. We have seen nothing in this 
special line of study that will compare in point of 
accuracy of detail and artistic effect with the work 
under consideration." — Maryland Med. Journal. 



ELEMENTS OF MODERN MEDICINE, including Princi- 

pies of Pathology and Therapeutics, with many Useful Memoranda and 
Valuable Tables of Reference. Accompanied by Pocket Fever Charts. 
Designed for the Use of Students and Practitioners of Medicine. By R. 
French Stone, M. D., Professor of Materia Medica and Therapeutics and 
Clinical Medicine in the Central College of Physicians and Surgeons, 
Indianapolis ; Physician to the Indiana Institute for the Blind ; Consulting 
Physician to the Indianapolis City Hospital, etc., etc. 
In wallet-book form, with pockets on each cover for Memoranda, Temperature Charts, etc., $2.50. 



"This is an abridged work in pocket-book form, 
presenting the more advanced views of leading 
authorities, with reference to general pathology and 
therapeutics. Under general pathology are included 
articles on the origin, nature, and duration of dis- 
ease, chief symptoms, diagnosis, prognosis, and 
treatment. In the second part will be found what is 
regarded by the author as an improved classification 
of drugs, followed by articles on their physiological 
action, indications, and methods of use. The work 
contains a fund of useful information culled from 
the best authorities in the Old and New World." — 
Canada Lancet. 



' ' This is a neatly printed pocket manual of medi- 
cal practice. It is a well-condensed compilation of 
the kind, containing a short sketch of nearly every- 
thing that is met with in practice. The fever charts 
are well arranged, and there is a convenient thera- 
peutic table which will be found valuable. It will 
probably be more suitable for young practitioners, 
on account of its containing many practical points 
that are not to be found elsewhere in such a con- 
densed manner. It will be found a valuable aid to 
those just commencing practice." — Medical Herald. 



4 8 



D. APPLETON &» CO:S MEDICAL WORKS. 



A TEXT-BOOK OF OPHTHALMOSCOPY. By Edward 

G. Loring, M. D. Part I. — The Normal Eye, Determination of Refrac- 
tion, and Diseases of the Media. 

Specimen of Illustration. 



8vo. 267 pp., with 131 
Illustrations, and Four 
Chromo -Lithograph Plates, 
containing 14 Figures. 
Cloth, $5.00. 



41 The ' Text-book of Oph- 
thalmoscopy,' by Edward G. 
Loring, M. D., is a splendid 
work. ... I am well pleased 
with it, and am satisfied that 
it will be of service both to 
the teacher and pupil. . . . 
In this book Dr. Loring has 
given us a substantial exposi- 
tion of Nature's deeds and 
misdeeds as they are found 
written in the eye, and the 
key by means of which they 
can be comprehended." — W. 
R. Amick, A. M., M. D., Pro- 
fessor of Ophthalmology and 
Otology, Cincinnati College 
of Medicine and Surgery. 



THE DISEASES OF SEDENTARY AND ADVANCED 

LIFE. A Work for Medical and Lay Readers. By J. Milner Foth- 
ergill, M. D., M. R. C. P., Physician to the City of London Hospital for 
Diseases of the Chest (Victoria Park) ; late Assistant Physician to the West 
London Hospital ; Hon. M. D., Rush Medical College, Chicago ; Foreign 
Associate Fellow of the Royal College of Physicians of Philadelphia. 
Small 8vo, 296 pp. Cloth, $2.00. 




"This work is written to fill a gap in medical 
literature. The diseases of sedentary and advanced 
life lie a little outside and beyond the ordinary text- 
books of practice of physic. As such a work is cer- 
tain to be read by lay-readers, the fact has not been 



forgotten. . . . The writer ventures to think that in 
this work an aspect of disease is presented which is 
not always kept sufficiently in view ; and which will 
make the work acceptable even to some well-read 
members of the profession. " — From the Preface. 



THE DIAGNOSIS AND TREATMENT OF DISEASES 

OF THE EAR. By Oren D. Pomeroy, M. D., Surgeon to the Manhat- 
tan Eye and Ear Hospital, etc. With One Hundred Illustrations. New- 
edition, revised and enlarged. 

8vo. Cloth, $3.00. 



"The several forms of aural disease are dealt 
with in a manner exceedingly satisfactory. The 
work is quite exhaustive in its scope, and will repre- 
sent an authority on this subject which we believe 
will be duly appreciated by the profession." — Medi- 
cal Record. 

''The author uses good language, telling in a 
clear and interesting manner what he has to say. 
The book is a valuable one for both students and 
practitioners." — Lancet and Clinic. 



"The author's opportunity to know of what he 
writes has been abundant, and the work itself shows 
that he has made good use of his information. We 
have not the slightest reason for not commending it 
not only to the otologist but also to the general 
student. " — Therapeutic Gazette. 

" Well arranged and well written, and not too 
scientific.'' — Boston Medical and Surgical Jour- 
nal. 



D. APPLETON &* CO.'S MEDICAL WORKS. ^g 

PRACTICAL SUGGESTIONS RESPECTING THE 

VARIETIES OF ELECTRIC CURRENTS AND THE USES OF 
ELECTRICITY IN MEDICINE, with Hints relating to the Selection 
and Care of Electrical Apparatus. By Ambrose L. Ranney, M. D., Pro- 
fessor of Nervous Diseases in the Medical Department of the University of 
Vermont ; Professor of the Anatomy and Physiology of the Nervous System 
in the New York Post-Graduate Medical School and Hospital, etc. 

l6mo, 147 pp., with 44 Illustrations and 14 plates, as an aid in treating morbid states of the motor 

or sensory apparatus. $1.00. 

A TEXT-BOOK OF NURSING. For the Use of Training- 

Schools, Families, and Private Students. Compiled by Clara S. Weeks, 

Graduate of the New York Hospital Training-School ; Superintendent of 

Training-School for Nurses, Paterson, New Jersey. 

l2mo, 396 pp., with 13 Illustrations, Questions for Review and Examination, and Vocabulary of 

Medical Terms. $1.75. 

" This book, in twenty-three chapters, communi- provingly of its design, scope, and execution." — 

cates a large quantity of useful information in a Philadelphia Medical Times. 
form intelligible to the public. It is well written, 

remarkably correct, sufficiently illustrated, and hand- " This is an admirably written book, and is full 

somely printed. The amount of technical skill and of those important practical details necessary for 

knowledge required of nurses at the present day the medical and surgical nurse. In fact, it could be 

makes the use of some text-book indispensable. read with profit by every medical student and young 

To those who need such a work we can speak ap- practitioner." — Medical Record. 

LOCAL ANESTHESIA IN GENERAL MEDICINE 

AND SURGERY. Being the Practical Application of the Author's Re- 
cent Discoveries in Local Anaethesia. By J. Leonard Corning, M. D., 
author of "Brain Exhaustion," "Carotid Compression," " Brain Rest," etc. ; 
Fellow of the New York Academy of Medicine, Member of the Medical 
Society of the County of New York, of the New York Neurological 
Society, etc. 

Small 8vo, 103 pp. With 14 Illustrations. Cloth, $1.25. 

THE METHODS OF BACTERIOLOGICAL INVESTI- 

GATION. By Ferdinand Hueppe, Docent in Hygiene and Bacteriology 
in the Chemical Laboratory of R. Fresenius, at Wiesbaden. Written at the 
request of Dr. Robert Koch. Translated by Hermann M. Biggs, M. D., 
Instructor in the Carnegie Laboratory, and Assistant to the Chair of Patho- 
logical Anatomy in Bellevue Hospital Medical College. 
8vo, 218 pp. With 31 Illustrations. Cloth, $2.50. 

GYNECOLOGICAL TRANSACTIONS, VOL. VIII. 

Being the Proceedings of the Eighth Annual Meeting of the American 

Gynaecological Society, held in Philadelphia, September 18, 19, and 20, 

1883. 

8vo, 276 pp. Cloth, $5.00. 

GYNAECOLOGICAL TRANSACTIONS, VOL. IX. Be- 
ing the Proceedings of the Ninth Annual Meeting of the American Gynaeco- 
logical Society, held in Chicago, September 30, and October 1 and 2, 1884. 
8vo, 000 pp. Cloth, $5.00. 



INDEX. 



PAGE 

Air, Essays on the Floating Matter of the 27 

Anaesthesia, Local, in General Medicine and 

Surgery 49 

Anatomy, Atlas of Female Pelvic 39 

Of the Nervous System 28 

Physiology and Hygiene, The Essentials of. 44 

The Comparative, of the Domesticated 

Animals. 12 

The, of Invertebrated Animals 22 

The, of Vertebrated Animals 17 

Animal Diseases, The Relation of, to the Public 

Health 45 

Aorta, Diseases of the Heart and Thoracic 44 

Bacteriological Investigation, The Methods of.. 49 

Barker. On Sea-Sickness 3 

The Puerperal Diseases 3 

Bartholow. A Treatise on the Practice of Medi- 
cine 6 

On the Antagonism between Medicines. ... 7 

Treatise on Materia Medica and Therapeu- 
tics 5 

Bastian. Paralysis from Brain Disease 3 

The Brain as an Organ of Mind 5 

Bennet. On the Treatment of Pulmonary Con- 
sumption 7 

Winter and Spring on the Shores of the 

Mediterranean 7 

Bile, Jaundice, and Bilious Diseases, On the... 19 
Billings. The Relation of Animal Diseases to 

the Public Health 45 

Billroth. General Surgical Pathology and Thera- 
peutics 8 

Body and Mind 24 

Bones, A Treatise on Diseases of the 26 

Brain Disease, Paralysis from 3 

Exhaustion, A Treatise on 43 

The, and its Functions 36 

The, as an Organ of Mind 5 

Bramwell. Diseases of the Heart and Thoracic 

Aorta 44 

Breath, The, and the Diseases which give it a 

Fetid Odor 19 

Buck. Contributions to Reparative Surgery .... 14 

Carpenter. Principles of Mental Physiology 4 

Carter. Elements of Practical Medicine 39 

Chauveau. The Comparative Anatomy of the 

Domesticated Animals 12 

Chemical Technology, A Hand-book of 33 

Chemistry, Inorganic 35 

Organic 35 

Short Text-book of Organic 4 

The, of Common Life 14 

Children, A Practical Treatise on Diseases of. . 38 

Children's Diseases, Compendium of 30 

Club-Foot, A Practical Manual on the Treat- 
ment of 30 

Combe. The Management of Infancy 3 

Consumption, on the Treatment of Pulmonary. . 7 

Corfield. On Health 4 

Corning. A Treatise on Brain-Exhaustion 43 

Local Anaesthesia in General Medicine and 

Surgery 49 

Cyclopaedia of Practical Receipts 12 

Davis. Conservative Surgery 13 

Deformities, A Treatise on Oral 18 

Dermatology, A Manual of 47 

Diseases, The, of Sedentary and Advanced Life. 48 

Down. Health Primers 21 

Ear, The Diagnosis and Treatment of Diseases 

of the 48 

Education, Physical 25 

Electricity in Medicine, The Uses of 49 

Elliot. Obstetric Clinic 9 

Emergencies, and How to Treat them 16 

Evetzky. The Physiological and Therapeutical 
Action of Ergot 8 



Eye, A Hand-book of the Diseases of the, and 

their Treatment 44 

Flint. Manual of Chemical Examination of the 

Urine in Disease 9 

Medical Ethics and Etiquette . 46 

On the Physiological Effects of Severe and 

Protracted Muscular Exercise 9 

Text-book of Human Physiology 10 

The Physiology of Man n 

The Source of Muscular Power 9 

Foods 33 

Fothergill. The Diseases of Sedentary and Ad- 
vanced Life 48 

Fournier. Syphilis and Marriage 11 

Frey. The Histology and Histo-Chemistry of 

Man 13 

Friedlaender. The Use of the Microscope in 
Clinical and Pathological Examinations ... 46 

Gamgee. Yellow Fever a Nautical Disease 13 

Genito-Urinary Organs, Surgical Diseases of the. 33 
Gross. A Practical Treatise on Tumors of the 

Mammary Gland 15 

Gutmann. The Watering- Places and Mineral 
Springs of Germany, Austria, and Switzer- 
land 30 

Gynaecological Transactions. Vols. VIII and IX. 49 

Hamilton. Clinical Electro-Therapeutics 22 

Hammond. A Treatise on Insanity 40 

A Treatise on the Diseases of the Nervous 

System 16 

Clinical Lectures on Diseases of the Nerv- 
ous System 17 

Hart. Atlas of Female Pelvic Anatomy 39 

Harvey. First Lines of Therapeutics 19 

Health 4, 31 

A Ministry of, etc 29 

And How to Promote it 24 

Primers 21 

Heart and Thoracic Aorta, Diseases of the 44 

Histology and Histo-Chemistry, The, of Man.. 13 
Hoffman and Ultzmann. Analysis of the 

Urine / 22 

Hospital Reports. — Bellevue and Charity 32 

Hospitals 35 

Howe. Emergencies, and How to Treat them . 16 

The Breath, and the Diseases which give it 

a Fetid Odor 19 

Hueppe. The Methods of Bacteriological In- 
vestigation 49 

Huxley. The Anatomy of Invertebrated Ani- 
mals 22 

The Anatomy of Vertebrated Animals 17 

Hygiene, Physiology, and Anatomy, The Essen- 
tials of , 44 

Infancy, The Management of 3 

In-Knee, Medical and Surgical Aspects of 36 

Insanity, A Treatise on 40 

Jaccoud. The Curability and Treatment of 

Pulmonary Phthisis 46 

Johnson. The Chemistry of Common Life 14 

Joints, Lectures on Orthopedic Surgery and 

Diseases of the 31 

Jones. Practical Manual of Diseases of Women 

and Uterine Therapeutics 43 

Journal, The New York Medical 38 

Keyes. The Tonic Treatment of Syphilis 14 

Kingsley. A Treatise on Oral Deformities .... 18 
Legg. On the Bile, Jaundice, and Bilious 

Diseases 19 

Letterman. Medical Recollections of the Army 

of the Potomac 24 

Life, Diseases of Modern 30 

The Diseases of Sedentary and Advanced . . 48 

Little. Medical and Surgical Aspects of In-Knee. 36 

Loring. A Text-book of Ophthalmoscopy 48 

Lusk. The Science and Art of Midwifery 20 



